Features of medical records in community practices and their association with preventive service delivery.
BACKGROUND
Medical records are important for facilitating the process and quality of care. However, little is known about their current state in primary care practices. This article describes features of medical record systems in diverse practices and examines their association with preventive service delivery rates.


METHODS
Medical records were reviewed from a consecutive sample of outpatients seen by 198 family physicians in 79 community-based practices in Northeast Ohio. The physicians were participants in a clinical trial designed to increase preventive service delivery. Research nurses performed baseline medical record reviews and used ethnographic field notes and a practice environment checklist to provide global assessments of features of medical records.


RESULTS
In 79 practices, 3462 medical records were reviewed. Medical records were rated as highly easy to use in 52% of practices; outpatient visit notes were dictated in 54%. Nine percent of practices grouped individual charts by family. Patient notes were computerized in 1% of practices, although several practices had previously tried and abandoned computerized systems. Flow sheets for immunization, screening, and counseling were present on 71%, 63%, and 16% of charts and were used on 34%, 33%, and 3% of charts, respectively. The presence and use of flow sheets were associated with higher preventive service delivery rates.


CONCLUSIONS
Medical record organization, completeness, and use vary widely, and computerized records remain rare. The association of flow sheet presence and use with preventive service delivery rates shows the potential importance of medical records for enhancing the process and outcome of patient care.
Weyer
Sharon M
SM
Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio 44106, USA. Sharon.Weyer@case.edu
Konrad
Nancy
N
Esola
Diane
D
Goodwin
Meredith A
MA
Stange
Kurt C
KC
Flocke
Susan A
SA
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004282:Documentation; D005194:Family Practice; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D009820:Ohio; D011314:Preventive Health Services / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*