British journal of urology · 1997
The accuracy of recording of occupational history in patients with bladder cancer.
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McCahy P J, Harris C A, Neal D E
Аннотация
OBJECTIVE: To determine how accurately information on the occupations of patients with transitional cell carcinoma of the bladder (TCC) was recorded.
PATIENTS AND METHODS: Using a semi-structured interview and a standard proforma, 108 patients with TCC of the urinary tract were studied and the results compared with records in their case notes.
RESULTS: Case notes were substantially correct in only 39% of patients. Occupations that might have been a significant factor in the aetiology of TCC were omitted in 71% of potentially exposed male patients and no occupational history was recorded in 12% of all patients.
CONCLUSIONS: Important clinical information was missing from the case notes that might have been of practical use in determining whether patients might be eligible for financial redress and which might be of use in future clinical research. It is recommended that details of occupational history should be taken using a structured proforma; this could be a suitable topic for regular audit.
PATIENTS AND METHODS: Using a semi-structured interview and a standard proforma, 108 patients with TCC of the urinary tract were studied and the results compared with records in their case notes.
RESULTS: Case notes were substantially correct in only 39% of patients. Occupations that might have been a significant factor in the aetiology of TCC were omitted in 71% of potentially exposed male patients and no occupational history was recorded in 12% of all patients.
CONCLUSIONS: Important clinical information was missing from the case notes that might have been of practical use in determining whether patients might be eligible for financial redress and which might be of use in future clinical research. It is recommended that details of occupational history should be taken using a structured proforma; this could be a suitable topic for regular audit.