Literature DB >> 11825220

Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data.

J R Logan1, P N Gorman, B Middleton.   

Abstract

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.

Entities:  

Mesh：

Year:  2001        PMID： 11825220      PMCID： PMC2243504     

Source DB:  PubMed          Journal:  Proc AMIA Symp        ISSN： 1531-605X


  6 in total

1.  Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters.

Authors:  Z E Zuckerman; B Starfield; C Hochreiter; B Kovasznay
Journal:  Pediatrics       Date:  1975-09       Impact factor: 7.124

Review 2.  Accuracy of data in computer-based patient records.

Authors:  W R Hogan; M M Wagner
Journal:  J Am Med Inform Assoc       Date:  1997 Sep-Oct       Impact factor: 4.497

3.  Assessment of the completeness and accuracy of computer medical records in four practices committed to recording data on computer.

Authors:  M Pringle; P Ward; C Chilvers
Journal:  Br J Gen Pract       Date:  1995-10       Impact factor: 5.386

4.  Measuring physicians' performances by using simulated patients.

Authors:  G R Norman; V R Neufeld; A Walsh; C A Woodward; G A McConvey
Journal:  J Med Educ       Date:  1985-12

5.  Measuring medical residents' chart-documentation practices.

Authors:  M T Moran; T H Wiser; J Nanda; H Gross
Journal:  J Med Educ       Date:  1988-11

6.  The validity of the medical record.

Authors:  F J Romm; S M Putnam
Journal:  Med Care       Date:  1981-03       Impact factor: 2.983
  6 in total
  16 in total

1.  The effect of standardized, computer-guided templates on quality of VA disability exams.

Authors:  Elliot M Fielstein; Steven H Brown; Caroll S McBrine; Terry K Clark; Shawn P Hardenbrook; Ted Speroff
Journal:  AMIA Annu Symp Proc       Date:  2006

2.  Preliminary development of the physician documentation quality instrument.

Authors:  Peter D Stetson; Frances P Morrison; Suzanne Bakken; Stephen B Johnson
Journal:  J Am Med Inform Assoc       Date:  2008-04-24       Impact factor: 4.497

3.  A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians.

Authors:  Rubina F Rizvi; Kathleen A Harder; Gretchen M Hultman; Terrence J Adam; Michael Kim; Serguei V S Pakhomov; Genevieve B Melton
Journal:  Int J Med Inform       Date:  2016-03-02       Impact factor: 4.046

4.  Enhancing medical evaluations of sick-listed employees: an educational intervention to improve professional practice of physicians performing work ability assessments of employees on long-term sick leave.

Authors:  Patricia M Dekkers-Sánchez; Annette E de Wind
Journal:  Int Arch Occup Environ Health       Date:  2019-01-23       Impact factor: 3.015

5.  Variation in Physicians' Electronic Health Record Documentation and Potential Patient Harm from That Variation.

Authors:  Genna R Cohen; Charles P Friedman; Andrew M Ryan; Caroline R Richardson; Julia Adler-Milstein
Journal:  J Gen Intern Med       Date:  2019-06-10       Impact factor: 5.128

6.  Data quality in the outpatient setting: impact on clinical decision support systems.

Authors:  Eta S Berner; Ramkumar K Kasiraman; Feliciano Yu; Midge N Ray; Thomas K Houston
Journal:  AMIA Annu Symp Proc       Date:  2005

7.  Method of electronic health record documentation and quality of primary care.

Authors:  Jeffrey A Linder; Jeffrey L Schnipper; Blackford Middleton
Journal:  J Am Med Inform Assoc       Date:  2012-05-19       Impact factor: 4.497

8.  Defining and measuring completeness of electronic health records for secondary use.

Authors:  Nicole G Weiskopf; George Hripcsak; Sushmita Swaminathan; Chunhua Weng
Journal:  J Biomed Inform       Date:  2013-06-29       Impact factor: 6.317

9.  Validating the extract, transform, load process used to populate a large clinical research database.

Authors:  Michael J Denney; Dustin M Long; Matthew G Armistead; Jamie L Anderson; Baqiyyah N Conway
Journal:  Int J Med Inform       Date:  2016-07-29       Impact factor: 4.046

10.  Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitor-Based Treatment on Cardiovascular Outcomes in Hypertensive Blacks Versus Whites.

Authors:  Gbenga Ogedegbe; Nirav R Shah; Christopher Phillips; Keith Goldfeld; Jason Roy; Yu Guo; Joyce Gyamfi; Christopher Torgersen; Louis Capponi; Sripal Bangalore
Journal:  J Am Coll Cardiol       Date:  2015-09-15       Impact factor: 24.094
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