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
PDF
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]