Concordance of the ambulatory medical record and patients' recollections of aspects of an ambulatory new-patient visit.
The ambulatory medical record should provide an accurate account of what took place during an outpatient visit. If it does not, the record cannot be used to judge many aspects of the quality of care, including physician-patient communication. The author evaluated the accuracy of the ambulatory medical record by comparing the results of structured telephone interviews with 40 patients following new-patient visits with audits of the medical records. The evaluation focused on chief complaint and the patient's understanding of the diagnosis, medications and follow-up arrangement. The 95% confidence intervals of concordance rates between interview and audit were [1, 0.68] or better for all measures except understanding of diagnosis [0.73, 0.37]. The generally good rate of concordance between the ambulatory medical record and patient recollection for important indices of physician-patient communication suggests that the ambulatory medical record can be used to evaluate that aspect of ambulatory patient care.
D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D010045:Outpatients; D010353:Patient Education as Topic; D010817:Physician-Patient Relations