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January 1971

Quality Control and the Medical Record

Author Affiliations

Burlington, Vt

From the departments of medicine and community medicine, College of Medicine, University of Vermont, Burlington.

Arch Intern Med. 1971;127(1):101-105. doi:10.1001/archinte.1971.00310130105017

Quality control can be thought of at two levels of sophistication. One level attempts to seek out glaring errors and the other to reflect unequivocally the understanding that quality is the excellence with which a well defined function is fulfilled. There are gross questions: Did he sign the discharge? Are there progress notes? Did he do a routine serology? Did he get a stool guaiac test on the patient with anemia? Is he more than two weeks behind in discharge summaries? Is there gross evidence of fluid overload postoperatively such as massive edema or solid wet lungs at autopsy? Does he wake patients up unnecessarily in the middle of the night? Does he make reasonable explanations to patients, referring physicians, and to families? This level of quality control and the usual death conferences with off-the-cuff comments and questions can continue with profit as long as serious faults are found in

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