A chart audit peer review system in an ambulatory service.
A system of providing rapid review of ambulatory patient records using a set of criteria was developed and tested. Of 337 records selected for review, 25% were not reviewable. Of the remaining 75%, virtually one half proved to be lacking in one or more of the established criteria. Deficiencies tended to occur most often in criteria related to the physical examination of the child. Physician compliance with the criteria could not be conclusively shown to improve during the five-month study period, although physician acceptability was judged as good. A large percentage (47.3%) of deficient records could be corrected by the responsible health professional. The chief advantages of the system are that it is rapid and easy to perform. It focuses on the major service provided by the facility, i.e., acute medical care, and on the performance of the individual providing that service.
D000553:Ambulatory Care / Q000592:standards*; D003933:Diagnosis; D004636:Emergency Service, Hospital; D006776:Hospitals, Pediatric / Q000592:standards; D006801:Humans; D008485:Medical Audit; D008487:Medical History Taking; D008499:Medical Records; D010348:Patient Care Team; D010372:Pediatrics / Q000592:standards*; D010380:Peer Review; D010808:Physical Examination