Data retrieval in the coronary care unit: prospective vs. retrospective.
A standardized system for recording patient care data for medical audit was developed and implemented in six community hospitals' coronary care units. It utilized the principles of predefining the data base and having both nurses and physicians participate. This system was compared with conventional retrospective record abstraction as a source of information for medical audit. The results suggest that the proposed system produces slightly more clinical data relevant to diagnostic impressions. Accuracy is comparable to that achieved by standard computerized abstraction procedures. Such an approach is readily adaptable for implementing medical audit to meet the requirements currently imposed upon community hospitals.
D003325:Coronary Care Units; D007256:Information Systems; D008485:Medical Audit; D008497:Medical Record Administrators / Q000706:statistics & numerical data; D008499:Medical Records / Q000592:standards; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data; D009741:Nursing Staff, Hospital / Q000706:statistics & numerical data; D011446:Prospective Studies; D012189:Retrospective Studies