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DOI: 10.1055/s-0038-1634016
The Use of a Structured Form during Urology Out-patient Consultations
A Randomised Controlled TrialPublikationsverlauf
Received 21. Juli 2004
accepted: 25. Januar 2005
Publikationsdatum:
07. Februar 2018 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00035037/200505/lookinside/thumbnails/10-1055-s-0038-1634016-1.jpg)
Summary
Objectives: To compare the completeness of documentation in the medical record using a structured form (SF) versus a traditional medical record (TMR).
Methods: Randomised controlled trial comparing the use of SF and TMR in urology out-patient clinics for documentation of 15 items of clinical information, time taken to complete and acceptability to clinicians assessed by a self-completion questionnaire. in a teaching and district general hospitals
Results: Four hundred new urology patient consultations, 11 clinicians. Completeness of information was compared between groups based on the medical record alone (SF vs. TMR), medical record plus letter to GP and letter alone. SFs were significantly (p<0.0001) more complete than TMRs for the majority of the items in all three groups. There was no significant difference in the time taken to document information using either type of record. The clinicians generally found the SF acceptable for routine use.
Conclusions: Structured forms significantly improved the completeness of documentation for new out-patient consultations in urology.
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