title: Quality of patient record keeping: an indicator of the quality of care?
abstract: BACKGROUND
  Patient record review of hospitalised patients is by far the most applied method to assess adverse events (AEs) in hospitals. The diligence with which information is recorded may influence the visibility of AEs. On the other hand, poor quality of the information in patient records may be a cause or a consequence of poor quality of care and may thus be associated with higher rates of AEs. The objective of this study was to assess the relation between the quality of patient records and the occurrence of AEs.
  
  
  METHODS
  In this study, 7926 hospital admissions of 21 Dutch hospitals were analysed with a structured record review method. The occurrence of AEs, the presence of patient information and the quality of the present information (completeness, readability and adequacy) were assessed. Their association was analysed using multilevel logistic regression analyses.
  
  
  RESULTS
  The absence of record components was associated with lower rates of AEs, suggesting that missing record components lead to an underassessment of AEs in record-review studies. In contrast, poor quality of the information present in patient records was associated with higher rates of AEs, implying that the quality of the present patient information is a predictor of the quality of care.
  
  
  CONCLUSIONS
  Evidence-based standards and a (electronic) format for record keeping are necessary for standardisation of recording patient information. This will improve the completeness, readability, accessibility, accuracy and exchange of patient information between healthcare providers and institutions. Better registration of patient information will benefit the quality of the healthcare process and will reduce the risk of AEs.
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands. m.zegers@iq.umcn.nl
authors.forename: Marieke
authors.initials: M
authors.lastname: Zegers
authors.forename: Martine C
authors.initials: MC
authors.lastname: de Bruijne
authors.forename: Peter
authors.initials: P
authors.lastname: Spreeuwenberg
authors.forename: Cordula
authors.initials: C
authors.lastname: Wagner
authors.forename: Peter P
authors.initials: PP
authors.lastname: Groenewegen
authors.forename: Gerrit
authors.initials: G
authors.lastname: van der Wal
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D008499:Medical Records / Q000592:standards*; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies