Improving problem oriented medical records through self-audit
- PMID: 6965502
Improving problem oriented medical records through self-audit
Abstract
In a teaching family medical center a strategy was sought to improve the quality of medical record keeping. A study was undertaken to determine the usefulness of a standardized form for self-audit. Validity and reliability of the form were established and it was shown that there was a significant improvement in the study group three weeks after the exposure period, as compared to a control group. Improvements occurred particularly in the recording of drugs prescribed and in the linkage of progress notes to the problem list. Despite this improvement, linkage to the problem list was seen to occur in only half of the studied charts. With modification the self-audit form appears to be a useful stimulus to good record keeping.
Similar articles
-
Documentation of family health history in the outpatient medical record.J Fam Pract. 1986 Feb;22(2):169-74. J Fam Pract. 1986. PMID: 3484779
-
Quality assurance: an approach.Physiother Can. 1979 Jan-Feb;31(1):11-4. Physiother Can. 1979. PMID: 10295012
-
Observer variation in an audit of charts of patients with rheumatoid arthritis.Physiother Can. 1992 Spring;44(2):26-32. Physiother Can. 1992. PMID: 10119257
-
An audit of the quality of deployed DMICP records on Operation HERRICK 14.J R Army Med Corps. 2012 Sep;158(3):213-6. doi: 10.1136/jramc-158-03-13. J R Army Med Corps. 2012. PMID: 23472568 Review.
-
Evaluating the quality of ambulatory health care: a review of emerging methods.Med Care. 1977 Nov;15(11):877-97. doi: 10.1097/00005650-197711000-00001. Med Care. 1977. PMID: 336992 Review.
Cited by
-
The impact of feedback to medical housestaff on chart documentation and quality of care in the outpatient setting.J Gen Intern Med. 1997 Jun;12(6):352-6. doi: 10.1046/j.1525-1497.1997.00059.x. J Gen Intern Med. 1997. PMID: 9192252 Free PMC article.
-
The CRABEL score--a method for auditing medical records.Ann R Coll Surg Engl. 2001 Jan;83(1):65-8. Ann R Coll Surg Engl. 2001. PMID: 11212456 Free PMC article.
-
Use of an outpatient medical record audit to achieve educational objectives: changes in residents' performances over six years.J Gen Intern Med. 1990 May-Jun;5(3):218-24. doi: 10.1007/BF02600538. J Gen Intern Med. 1990. PMID: 2341921
-
[Recording of drug prescriptions in medical records. How to improve the quality?].Can Fam Physician. 1996 Nov;42:2193-7. Can Fam Physician. 1996. PMID: 8974553 Free PMC article. Clinical Trial.
-
[Self-auditing as an instrument of educational assessment].Aten Primaria. 2005 Feb 28;35(3):121. doi: 10.1157/13071935. Aten Primaria. 2005. PMID: 15737266 Free PMC article. Spanish. No abstract available.