Improving problem oriented medical records through self-audit.
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.
D000046:Academic Medical Centers; D005194:Family Practice / Q000193:education*; D007396:Internship and Residency; D008485:Medical Audit / Q000379:methods*; D008499:Medical Records / Q000592:standards*; D008501:Medical Records, Problem-Oriented / Q000592:standards*; D009864:Ontario