[The ambulatory patient history: an attempt at quality control]

At the medical outpatient clinic of the university of Zurich a sample of 200 records, 100 each from male and female patients was taken and analyzed to assess the quality of record-keeping. An average to acceptable quality was found regarding history, physical examination, diagnostic evaluation and treatment. Next to incomplete registration of anamnestic and clinical data deficiencies consisted in neglect of outdated or less important items of the check-list. Time-consuming or disagreeable procedures such as ophthalmoscopy or rectal examination could hardly be analyzed since the physician had often not indicated whether he had performed the procedure or found a normal state. Although evaluation of fitness to work was expected it was rarely documented and could not be analyzed. Check-lists for medical records should thus be adapted more frequently to meet changing demands. Periodic reviews of record-quality should serve to periodically inform doctors about deficiencies in their practice of patient work-up. Physicians should also be coerced to identify procedures that were not performed or which yielded normal findings.