Can the decision to operate be judged retrospectively? A study of medical records.
OBJECTIVE
To examine the precision and completeness of information in medical records for evaluating the appropriateness of operative indications for lumbar disc surgery.


METHODS
Retrospective review of records.


METHODS
University department of neurosurgery, Switzerland.


METHODS
100 patients.


METHODS
None.


METHODS
Proportion of pre-defined, detailed appropriateness criteria present in the records. Proportion of cases that could unequivocally be classified as to the appropriateness of the indication for operation.


RESULTS
The criteria were present and precise for 52 of the items (range 9-90); present but imprecise for 38 of the items, and absent for 10. Because of this imprecision, the appropriateness of only 7 of the operative indications could be unequivocally assessed retrospectively.


CONCLUSIONS
Medical records are of limited use in assessing the appropriate management of care. The process of care should therefore be evaluated prospectively.
Jeannot
J G
JG
Institute of Social and Preventive Medicine (IUMSP), University of Lausanne Hospital (CHUV), Switzerland.
Vader
J P
JP
Porchet
F
F
Larequi-Lauber
T
T
Burnand
B
B
D005260:Female; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000453:epidemiology / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D017064:Process Assessment, Health Care / Q000379:methods*; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data