Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data.
This paper explores the attributes of quality in recorded clinical encounter data, examines issues in measuring these attributes, and describes a method for measuring two attributes, completeness and correctness. The method is defined in the context of computer-based records and is demonstrated in a pilot study. Videotaped physician-patient encounters and an empiric process of determining a gold standard for content are used. The methodology was found to be feasible. Problems encountered during the pilot study can be remedied.
Logan
J R
JR
Division of Medical Informatics and Outcomes Research, Oregon Health Sciences University, Portland, OR, USA.
Gorman
P N
PN
Middleton
B
B
D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D008722:Methods; D010817:Physician-Patient Relations; D010865:Pilot Projects; D011785:Quality Assurance, Health Care