An evaluation of medical records documentation in the Adult Cardiology Clinic at the Nork Marash Medical Center: a cross -sectional study

Abstract

Purpose. The study was conducted to evaluate medical records documentation in the Adult Cardiology Clinic (ACC) at Nork Marash Medical Center (NMMC). Introduction. Medical records are an important source of patient information used for quality assurance (QA), medical audit, reimbursement purposes, research, and education activities in developed countries. Patient records can serve as a defense against medical malpractice as well. However, before relying on medical records, the reliability and validity of their content should be evaluated. Several studies were conducted to assess the adequacy of medical records in various hospital and out patient settings. Some indicated incomplete and inaccurate recording of elicited patient information. Medical records were more inadequate in outpatient health care settings. The initial hospital survey identified that NMMC has a variety of medical records and databases that can be used to assure quality of care and to monitor health care outcomes over time. However, the validity of patient records and databases has never been evaluated. Methods. The study design was cross-sectional and data was collected prospectively. The accuracy and completeness of the first-visit structured encounter form (SEF) were assessed comparing the recorded information with the observation of the actual patient-cardiologist encounters, which was considered as the “gold standard”. Survey participants were 18 and more years old females and males admitted to the ACC for the first time. The instrument was developed based on the content of the first-visit SEF and was pre-tested. SEFs were reviewed approximately 30 days after the completion of observations, assigning full, partial, and no credit to each item. Sample. The sample size of the study was 66 patients. The hypothesized agreement between observations and records was agreement 85% and the least difference desirable to detect was 10%. There are five adult cardiologists at NMMC, four of whom participated in the study. The number of patients was represented in the sample proportionally to the volume of cardiologists’ practices. Ethical considerations. The research proposal was reviewed and approved by the Institutional Review Board (IRB) committee within the College of Health Sciences at the American University of Armenia (AUA). Results. The mean observation time was 29 min and the average auditing time was 4 min. The overall mean agreement between observations of the actual encounters and SEFs was 69.8%. Data analysis was performed to identify the percent agreement for each domain and variable. Study indicated excellent agreement for tests performed and ordered for patient, good agreement for patient complaints and physical examination results, and poor agreement for medical history and patient habits. Recording pattern was examined to indicate inaccurate, under-and over-recording for each item in the instrument. Generally, there was significant under-recording of positive and/or negative findings for patient complaints, medical history, and patient smoking status. There was identified also over-and under-recording of physical examination findings. The examination of validity measurements pointed out that SEFs are valid source of patient information in terms of tests performed and ordered for patients. Conclusions. Good overall agreement between observation of the actual cardiologist-patient encounter and SEF indicates that the first-visit SEF can be used as a source of patient data after appropriate improvements are designed and implemented. The study results emphasized the necessity of establishing guidelines for patient health assessment at the ACC, training on the completion of the first-visit SEF, and the establishment of the internal evaluation processes at NMMC.