The validity of the medical record

Abstract

The medical record is the source of information for many purposes, including evaluation of the quality of care provided. Despite this reliance on the record, there have been few attempts to validate the recorded content against the verbal content of the interaction between patient and physician. In this study, we compared the record with verbatim transcripts of outpatient visits. Overall, 59 per cent of units of information present in either source were found in the record. Recording was more complete for the chief complaint (92 per cent) and information related to the patient's present illness (71 per cent) than for other medical history (29 per cent). Incomplete recording of elicited information may partially explain the often low levels of performance of recommended care items found in quality-of-care studies. We suggest that more attention be paid to improving communication about tests and therapies to patients.