Abstract
BackgroundDocumentation 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.MethodsWe reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians) at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care.ResultsAmong internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 – 2.83) but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 – 0.75).ConclusionsMedical record documentation varied depending on the measure, with room for improvement in most domains. A variety of characteristics correlated with medical record documentation, but no pattern emerged. Further study could lead to targeted interventions to improve documentation.
Highlights
Documentation in the medical record facilitates the diagnosis and treatment of patients
Quality of documentation may reflect the quality of care delivered, recent studies have suggested that medical record documentation in the outpatient setting tends to underestimate the actual performance of preventive health care services and other indicators of quality care [2,3,4]
Determining the correlates of quality medical record documentation could lead to educational programs and other interventions to improve documentation, but few studies have rigorously examined the correlates of quality of chart documentation [7]
Summary
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 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. Electronic medical record (EMR) systems may improve the quality of care delivered as well as the documentation of that care in the outpatient setting, but few studies have examined this issue [5,6]. We 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 EMR. We studied the abstracted outpatient electronic medical records of 834 patients who received care from 117 internists and 50 pediatricians at 14 practice locations in 1998
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