Quality and correlates of medical record documentation in the ambulatory care setting

Abstract

Background: Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record.

How Good Are the Data? Feasible Approach to Validation of Metrics of Quality Derived From an Outpatient Electronic Health Record

“…As long as charting patterns in the EHRs remain fairly stable over time, the target populations will be comparable from time period to time period, and this weakness should have minimal impact. Another limitation is that manual review is an imperfect standard-both because clinicians may not document adequately 5,[22][23][24]27,[35][36][37][38][39] and because of the potential inaccuracies of manual record review. [40][41][42] However, as there is no other retrospective method available, it remains the best and most appropriate standard available for these purposes.…”

Simulations in the United States Medical Licensing ExaminationTM (USMLETM)

“…[33][34][35][36] Poor written documentation in the medical record has been identified in ambulatory and inpatient settings as having potential implications for healthcare quality. [37][38][39] Enhancements planned or under consideration for inclusion in Step 2 CS will allow for an even more robust assessment of physical examination skills, without posing safety risks to SPs.…”

Are we failing to document adequate smoking histories? A brief review 1999–2009

“…Inadequate documentation of smoking histories by primary care clinicians, specialists, residents, and medical students was found in 14 studies [6][7][8][9][10][16][17][18][19][20][21][22][23][24] . Failure to document smoking histories was observed in patients with conditions such as heart failure, coronary artery disease, and asthma.…”

“…Soto et al 20 reviewed the electronic medical records of 834 patients in a primary care practice (Harvard Vanguard Medical Associates) for quality of documentation. These patients were receiving care at 14 sites, including 117 internists and 50 pediatricians.…”