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Hospital records.

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Hospital Records↗

Birthweight and gestational age: mothers' estimates compared with state and hospital records.

Birthweight and gestational age estimates made by research subjects were compared with values obtained from birth certificates and hospital records. Ninety-one per cent of mothers' estimates of their infant's birthweight and 88 per cent of their estimates of infant gestational age agreed with the delivery record. When the same mothers estimated their own and their husband's birthweight, only 44 per cent were in agreement with birth certificate values; however, 78 per cent were in agreement with the pounds portion of the weight. Agreement of mothers' estimates of her own and her husband's gestational age with birth certificates was no better than chance.

Birth Certificates↗

Increasing incidence of clefts in Finland: reliability of hospital records and central register of congenital malformations.

The treatment of cleft lip and/or palate [CL(P), CP] in Finland has been centralized to one unit since 1947. Since 1963 all congenital malformations are reported to a central register. Comparison of these two materials showed that altogether 3928 children with clefts, born from 1948 to 1975, were registered in a total of 2 258 850 live born children in Finland, corresponding an incidence of 1.74%. There was a constant registered rise in the incidence from 1.31% in 1948-52 to 2.16% in 1969-75, indicating a corrected "true" increase in the incidence by 33% in 28 years, or approximately by over one percent per year. Of all registered clefts born 1963-75 23.5% were lacking from the Register of Congenital Malformations, and 10.3% from the hospital records. In 1948-75 55.8% of the clefts belonged to the group CP and 44.2% to CL(P). The incidence of CP increased from 0.78% in 1948-52 to 1.21% in 1969-75, and that of CL(P) from 0.53 to 0.95%. An average of 13,8% of the CP-cases were submucous clefts. Their registered incidence in all live born children increased from 0.08% in 1948-52 to 0.19% in 1969-75.

Adolescent↗

Follow up policy after treatment for Hodgkin's disease: too many clinic visits and routine tests? A review of hospital records.

OBJECTIVE: To examine the effectiveness of routine clinic review in detecting relapse after treatment for Hodgkin's disease. DESIGN: Review of hospital records. SETTING: Regional centre for cancer treatment and research. SUBJECTS: 210 patients with Hodgkin's disease recruited to a chemotherapy trial protocol between 1984 and the end of 1990 who had achieved a complete or partial remission after treatment. MAIN OUTCOME MEASURES: The number of clinic visits made by patients over the period of observation, the number of relapses occurring during that time, and the route by which relapse was detected. RESULTS: The 210 patients generated 2512 outpatient reviews, and 37 relapses were detected. Thirty relapses (81%) were diagnosed in patients who described symptoms, which in 15 cases had resulted in an earlier appointment being arranged. In only four cases (11%; 95% confidence interval 4% to 25%) was relapse detected as a result of routine physical examination on investigation of a patient who did not have symptoms. CONCLUSIONS: Relapse of Hodgkin's disease after treatment is usually detected as a result of the investigation of symptoms rather than by routine screening of asymptomatic patients. It is therefore proposed that the frequency of routine follow up visits should be reduced and greater emphasis placed on patient education. This should underline the importance of symptoms and encourage patients to arrange an earlier appointment if these develop.

Ambulatory Care↗

Evidential value of the hospital record in clinical decision making.

A simulated retrospective exercise in the diagnosis and management of 53 readmissions to a gastrointestinal unit was undertaken by two consultants. Diagnosis of the illness at readmission was made on evidence sought from a referee, who also supplied, on request, items of relevant evidence from the past medical record. Patient management was agreed from these sources. For each item of evidence the evidential weight, the irrecoverability, and the expected benefit accruing to the patient of its availability was calculated. It was concluded that the evidence worth recording in the event of subsequent hospital admission could be largely specified for each diagnosis and each operation. It would be brief and could be numerically coded.

Decision Making↗