Abstract
This paper explores the attributes of quality in recorded clinical encounter data, examines issues in measuring these attributes, and describes a method for measuring two attributes, completeness and correctness. The method is defined in the context of computer-based records and is demonstrated in a pilot study. Videotaped physician-patient encounters and an empiric process of determining a gold standard for content are used. The methodology was found to be feasible. Problems encountered during the pilot study can be remedied.
Full text
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Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Hogan W. R., Wagner M. M. Accuracy of data in computer-based patient records. J Am Med Inform Assoc. 1997 Sep-Oct;4(5):342–355. doi: 10.1136/jamia.1997.0040342. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Moran M. T., Wiser T. H., Nanda J., Gross H. Measuring medical residents' chart-documentation practices. J Med Educ. 1988 Nov;63(11):859–865. doi: 10.1097/00001888-198811000-00006. [DOI] [PubMed] [Google Scholar]
- Norman G. R., Neufeld V. R., Walsh A., Woodward C. A., McConvey G. A. Measuring physicians' performances by using simulated patients. J Med Educ. 1985 Dec;60(12):925–934. doi: 10.1097/00001888-198512000-00004. [DOI] [PubMed] [Google Scholar]
- Pringle M., Ward P., Chilvers C. Assessment of the completeness and accuracy of computer medical records in four practices committed to recording data on computer. Br J Gen Pract. 1995 Oct;45(399):537–541. [PMC free article] [PubMed] [Google Scholar]
- Romm F. J., Putnam S. M. The validity of the medical record. Med Care. 1981 Mar;19(3):310–315. doi: 10.1097/00005650-198103000-00006. [DOI] [PubMed] [Google Scholar]
- Zuckerman Z. E., Starfield B., Hochreiter C., Kovasznay B. Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters. Pediatrics. 1975 Sep;56(3):407–411. [PubMed] [Google Scholar]