Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters

Abstract

Information in 51 tape-recorded physician-patient encounters was compared with information written in the patients' medical records. Diagnoses, chief complaints, scheduled appointments, non-drug therapy, and diagnostic studies were uniformly well-recorded. Medication names were well-recorded but dosages were not. Characteristics of care such as levels of function, probable cause of illness, reason for follow-up, and compliance were recorded poorly. Patients were more likely to known about and understand their diagnosis, and names, dosage, and intended function of their medications when this information was written in the record than when it was not. These findings indicate a relationship between the quality of medical records and the effectiveness of care.