Practice patterns in outpatient rheumatology: a pilot evaluation of medical file content.
OBJECTIVE
High-quality medical records that contain detailed data on the patient and disease are essential to high-quality patient care. RHEVER is a network of hospital- and office-based rheumatologists created in 1999 to pursue a number of objectives, including the development of recommendations about items that should be recorded routinely at each patient visit. Subsequently, one of the RHEVER members investigated whether these recommendations were followed by RHEVER participants at a teaching hospital.


METHODS
A cross-section of paper-based outpatient files at the rheumatology clinic of the Cochin Teaching Hospital, Paris, France, was studied. The sample comprised 50 files taken at random and 30 files of patients with rheumatoid arthritis.


RESULTS
In the 50 unselected files, the reason for the visit was consistently provided, but the diagnosis was variably recorded and decisions about investigations and treatments were not always described. Of the 30 files in patients with rheumatoid arthritis, 75% contained the full set of recommended clinical items.


CONCLUSIONS
This pilot study establishes the feasibility of practice pattern evaluation by rheumatologists. A similar study should be conducted among office-based RHEVER participants. Follow-up investigations are needed to evaluate the impact of medical record evaluations on quality of care.
Fechtenbaum
Jacques
J
Rheumatology Department B, Cochin Teaching Hospital, AP-HP, and René Descartes Paris V University, Paris, France. Jacques.fechtenbaum@cch.ap-hop-paris.fr <Jacques.fechtenbaum@cch.ap-hop-paris.fr>
Lecoq d'André
France
F
Nataf
Henri
H
Hudry
Christophe
C
Listrat
Véroniqe Gaud
VG
Roux
Christian
C
Dougados
Maxime
M
D000553:Ambulatory Care / Q000379:methods*; D003430:Cross-Sectional Studies; D005602:France; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D008485:Medical Audit; D008499:Medical Records / Q000592:standards; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D017064:Process Assessment, Health Care / Q000379:methods; D012219:Rheumatology / Q000379:methods*