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A questionnaire about their approach to keeping office records was completed by 82 randomly selected family physicians in southern Alberta. The results suggest that although there were few manifestly inadequate recordkeepers, there were many areas for legitimate concern, especially the following:

1. Extremely brief notes

2. Limited attention to psychosocial data

3. Underutilization of the more efficient filing techniques

4. Poorly organized charts

5. Failure to exploit fully innovations which had been introduced into the records system

6. Inadequate protection of the records.

There is reason to believe that the standard of record-keeping in family practice is improving. A few small, simple changes in our record-keeping habits could effect a considerable acceleration of this process.

Computerization of physician practices is increasing. Stakeholders are demanding demonstrated value for their Electronic Medical Record (EMR) implementations. We developed survey tools to measure medical office processes, including administrative and physician tasks pre- and post-EMR implementation. We included variables that were expected to improve with EMR implementation and those that were not expected to improve, as controls. We measured the same processes pre-EMR, at six months and 18 months post-EMR. Time required for most administrative tasks decreased within six months of EMR implementation. Staff time spent on charting increased with time, in keeping with our anecdotal observations that nurses were given more responsibility for charting in many offices. Physician time to chart increased initially by 50%, but went down to original levels by 18 months. However, this may be due to the drop-out of those physicians who had a difficult time charting electronically.

OBJECTIVE: To assess the clinical performance of a representative non-volunteer sample of family physicians in metropolitan Montreal, Que. DESIGN: Assessment of clinical performance was based on inspection visits to offices, peer review of medical records, and chart-stimulated recall interviews. The procedure was the one usually followed by the Professional Inspection Committee of the Collège des médecins du Québec. SETTING: Family physicians' practices in metropolitan Montreal. PARTICIPANTS: One hundred randomly selected family physicians. INTERVENTIONS: For each physician, 30 randomly chosen patient charts with data on three to five previous visits were reviewed using explicit criteria and a standard scale using global scores from 1 to 5 (unacceptable to excellent). MAIN OUTCOME MEASURES: Scores were assigned for office practices; record keeping; number of continuing medical education (CME) activities; and quality of clinical performance assessed in terms of investigation plan, diagnostic accuracy, treatment plan, and relevance of care. RESULTS: Overall performance was judged to be good to excellent for 98% of physicians in their private practices; for 90% of physicians concerning CME activities; for 94% of physicians concerning their clinical performance in terms of quality of care; and for 75% of physicians as to record keeping. There was a link between record keeping and quality of care as well as between the number of CME activities and quality of care. CONCLUSION: The overall clinical performance of family physicians in the greater Montreal region is excellent.

Despite a quarter century of developments, few specialists directly use a computerized patient record, that fully replaces the paper chart. Because of the diversity of domains in specialized care, medical decision-making and the continuity of care may suffer from scattering of patient data over various records. The challenge was to develop a computerized patient record, that would be versatile enough to tailor it to specific needs, while keeping it uniform enough to permit physicians to share data on the same patient. In our CPR, the key that reconciles versatility with uniformity lies in the design of the data model. The CPR consists of a mother record with specialized sub-records, that all share the same data model. A physician can enlarge his scope for decision-making by consulting other specialized records on the same patient or by viewing the combined information of all sub-records without the need to convert data or to familiarize himself with different interfaces.

Traditional record-keeping in family practice, based on the model of hospital charts, gives rise to some serious problems, illustrated in this article by a patient with an allergy to penicillin. The “cumulative patient profile,” which separates pertinent information in the history from the continually updated information on short-term problems, can prevent repetitive history-taking and can make information easily accessible to busy physicians.

The purpose of this study was to investigate the current perceptions and practices of discussing firearm risk management with patients diagnosed with selected mental health problems. A three-wave survey was mailed to a national random sample of clinical psychologists and 339 responded (62%). The majority (78.5%) believed firearm safety issues were greater among those with mental health problems. However, the majority of clinical psychologists did not have a routine system for identifying patients with access to firearms (78.2%). Additionally, the majority (78.8%) reported they did not routinely chart or keep a record of whether patients owned or had access to firearms. About one-half (51.6%) of the clinical psychologists reported they would initiate firearm safety counseling if the patients were assessed as at risk for self-harm or harm to others. Almost half (46%) of clinical psychologists reported not receiving any information on firearm safety issues. Thus, the findings of this study suggest that a more formal role regarding anticipatory guidance on firearms is needed in the professional training of clinical psychologists.

This paper describes a computerized medical information system for long term care, which is relatively unexplored in automated medical record-keeping. APRIL* includes accounting, billing, census, payroll and elderly housing (HUD) systems as well, to enable a facility to use a single computer for all areas. The medical applications include physicians' orders, medication, treatment, restorative nursing care charts, functional and psychological assessments, patient care plans, utilization review summaries, and scheduling for certification of need for care, U.R. meetings, care planning, immunizations, doctor visits, clinic and consult visits, and laboratory, x-ray, EKG, and other tests and monitors. Current plans include production of R.N., L.P.N. and aide task lists, calculating of hours of care required based on problems and documented orders, procedures, and plans.

The programs run on Digital's PDP 11's, including the Micro/J-11, and use the RSTS/E operating system, and the BASIC PLUS language. There are facilities in five (5) states using APRIL*, both batch and online, and several scheduled for in house installation before the end of 1983.

'Indian' numerals, which are popular among the Arab population, were used to devise a new Snellen's visual acuity chart. The new chart has the advantages of a reading chart. It keeps the patient's interest, does not miss alexic patients, and is quicker to perform. It is also devoid of the many disadvantages of a kinetic response chart (the capital E letter or Landolt's broken rings), especially that of the limited option of test objects.

Basal body temperature recordings are extensively used to diagnose and treat infertility, but too great an emphasis on the interpretation of these charts might be counter-productive in managing these patients. Several gynaecologists who use temperature charts clinically were asked to score 60 charts taken from a selection of normal and infertile women, and their results were compared with those obtained by a group of non-experts. Since the full hormonal profiles had been obtained for each of the 60 charts the accuracy of the predictions could be assessed. About 80% of the temperature charts were correctly interpreted by both groups as being either ovulatory or anovulatory but the day of ovulation was predicted correctly for only about 34% of the charts. When the charts were examined retrospectively the thermal nadir was found to coincide with the luteinising hormone surge in 43% of the charts from normal subjects but in only 25% of those from the infertile patients. Predicting the day of ovulation from the temperature recording, particularly in infertile women, is clearly unjustified.

OBJECTIVE

To identify patient and physician characteristics associated with family physicians recording blood pressure (BP) measurements in the medical charts of their elderly patients.

DESIGN

Retrospective review of patients’ charts during a 12-month period and baseline questionnaire on the sociodemographic and practice characteristics of family physicians participating in the Community Hypertension Assessment Trial. The chart review collected data on patients’ demographics, cardiovascular risk factors, antihypertensive medications, number of visits to family physicians, and number of BP readings recorded.

SETTING

Non-academic family practices in Hamilton and Ottawa, Ont.

PARTICIPANTS

Data were abstracted from the charts of 55 randomly selected regular elderly patients (65 years old and older) from each of 28 participating family practices (N = 1540 charts).

MAIN OUTCOME MEASURE

Number of recordings of BP measurements in medical charts during a 12-month period.

RESULTS

About 16% (241/1540) of elderly patients had not had their BP recorded in their charts during the 12-month review period. Among this 16%, almost half (47%, 114/241) had not had a BP measurement recorded during the previous 24 months. Multivariate analysis indicated that the likelihood of BP recording increased with the number of visits made to family physicians and was greater among patients taking antihypertensive medications or diagnosed with hypertension. Physicians who had more recently graduated from medical school (≤ 24 years) were more likely to record BP measurements.

CONCLUSION

Hypertension guidelines recommend that, for patients at risk, BP be measured and recorded at each office visit. Although more than 84% of older patients had at least 1 BP reading documented in their charts, patients who were already diagnosed with hypertension or who made frequent visits to the office were more likely to have their BP measured and recorded. A more systematic approach to monitoring elderly patients who visit their family physicians less frequently or who are not currently diagnosed with hypertension is needed.

BACKGROUND: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. AIM: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. DESIGN OF STUDY: Retrospective cohort study. SETTING: Eighteen general practices in the Exeter Primary Care Trust. METHOD: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, depending on which medium stored the clinical information from consultations. RESULTS: More consultations were recorded in hybrid systems (median in 2 years = 11, interquartile range [IQR] = 6-18) than computer systems (median in 2 years = 9, IQR = 4-16.5) or paper systems (median in 2 years = 8, IQR = 5-14,): P <0.001. In a Poisson regression analysis, which included age, sex, and future cancer diagnosis, the rates of consultations recorded in paper and computer systems were 16% and 11% lower, respectively, than in hybrid systems. Fewer telephone consultations were recorded in paper systems, and fewer home visits in computer systems. Fewer symptoms were recorded in individual consultations on computer systems. Recording of absent symptoms and severity of symptoms was highest in paper systems. CONCLUSION: Hybrid systems of primary care record keeping document higher numbers of consultations than computer-only or paper-only systems. The quality of individual consultation recording is highest in paper-only systems. This has medicolegal implications and may impact upon continuity of care.

SUMMARY

This article surveys the use of pain charts or pain drawings in eliciting information about the location of pain symptoms from children and adolescents. While pain charts are widely used and have been incorporated in multidimensional pediatric pain questionnaires and diaries, they present a number of issues requiring further study. These include, in particular, the number and size of different locations or areas of pain that need to be differentiated; the age at which children are able to complete pain charts unassisted; and whether the intensity and other qualities of pain can be accurately recorded on pain charts by children and adolescents. Based on data currently available, it is suggested that the unassisted use of pain charts be restricted to children aged 8 years or over, while for clinical purposes many younger children can complete pain charts with adult support. Where the investigator’s interest is restricted to a few areas of the body, checklists of body parts may have greater utility than pain charts. A new pain chart adapted for use in studies of pediatric recurrent and chronic pain is presented.

BACKGROUND

New recommendations suggest that the 2000 Centers for Disease Control and Prevention (CDC) growth charts and body mass index (BMI) for age be used for Canadian children. Little information is available on how often growth parameters are documented in hospital settings.

OBJECTIVE

To determine the frequency of documentation of growth parameters in the medical records of a tertiary care paediatric hospital.

METHODS

A prospective, 14-day audit of 491 charts of children seen in the emergency department (ED) or admitted to a ward was performed to determine the frequency of documentation of height/length, weight, head circumference, BMI or weight for height, and presence of growth charts. Similar data were sought from the most recent clinic visit for all ward charts.

RESULTS

Growth parameters, aside from weight, were infrequently documented in the medical record. Height/length was documented in no ED charts and in 42% of ward charts. BMI or weight for height were almost never found, and growth charts were present in only 23% of ward charts, one clinic chart and one ED chart.

CONCLUSIONS

Rates of documentation of growth parameters in the teaching hospital setting were unacceptably low. Implementation of the use of the 2000 CDC growth charts will require not only education regarding BMI but also steps to encourage more regular measurement of height and use of shared growth charts in all areas of the hospital. A simple conceptualization framework for health care providers to use as a counselling tool is presented.

Literature results and personal experience show that intrusive modalities of presenting suggestions of computerized clinical practice guidelines are detrimental to the routine use of an information system. This paper describes a solution for smoothly integrating a guideline-based decision support system into an existing computerized clinical chart for patients admitted to a Stroke Unit. Since many years, the healthcare personnel were using a commercial product for the ordinary patients’ data management, and they were satisfied with it. Thus, the decision support system has been integrated keeping attention to minimize changes and preserve existing human-computer interaction. Our decision support system is based on workflow technology. The paper illustrates the middleware layer developed to allow communication between the workflow management system and the clinical chart. At the same time, the consequent modification of the graphical users' interface is illustrated.

The clinical chart remains the fundamental record of outpatient clinical care. As this information migrates to electronic form, there is an opportunity to create standard formats for transmitting these charts. This paper describes work toward a Portable Chart Format (PCF) that can represent the relevant aspects of an outpatient chart. The main goal of the format is to provide a packaging medium for outpatient clinical charts in a transfer of care scenario. A secondary goal is to support the aggregation of comparable clinical data for outcomes analysis. The syntax used for PCF is Extended Markup Language (XML), a W3C standard. The structure of the PCF is based on a clinically relevant view of the data. The data definitions and nomenclature used are based primarily on existing clinical standards.

Objective

The goal of this study was to assess the validity of the International Classification of Disease, 10th Version (ICD-10) administrative hospital discharge data and to determine whether there were improvements in the validity of coding for clinical conditions compared with ICD-9 Clinical Modification (ICD-9-CM) data.

Methods

We reviewed 4,008 randomly selected charts for patients admitted from January 1 to June 30, 2003 at four teaching hospitals in Alberta, Canada to determine the presence or absence of 32 clinical conditions and to assess the agreement between ICD-10 data and chart data. We then recoded the same charts using ICD-9-CM and determined the agreement between the ICD-9-CM data and chart data for recording those same conditions. The accuracy of ICD-10 data relative to chart data was compared with the accuracy of ICD-9-CM data relative to chart data.

Results

Sensitivity values ranged from 9.3 to 83.1 percent for ICD-9-CM and from 12.7 to 80.8 percent for ICD-10 data. Positive predictive values ranged from 23.1 to 100 percent for ICD-9-CM and from 32.0 to 100 percent for ICD-10 data. Specificity and negative predictive values were consistently high for both ICD-9-CM and ICD-10 databases. Of the 32 conditions assessed, ICD-10 data had significantly higher sensitivity for one condition and lower sensitivity for seven conditions relative to ICD-9-CM data. The two databases had similar sensitivity values for the remaining 24 conditions.

Conclusions

The validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions was generally similar though validity differed between coding versions for some conditions. The implementation of ICD-10 coding has not significantly improved the quality of administrative data relative to ICD-9-CM. Future assessments like this one are needed because the validity of ICD-10 data may get better as coders gain experience with the new coding system.

This study examined the reliability of hand-written and computerised records of birth data collected during the Birth to Ten study at Baragwanath Hospital in Soweto. The reliability of record-keeping in hand-written obstetric and neonatal files was assessed by comparing duplicate records of six different variables abstracted from six different sections in these files. The reliability of computerised record-keeping was assessed by comparing the original hand-written record of each variable with records contained in the hospital’s computerised database. These data sets displayed similar levels of reliability which suggests that similar errors occurred when data were transcribed from one section of the files to the next, and from these files to the computerised database. In both sets of records reliability was highest for the categorical variable infant sex, and for those continuous variables (such as maternal age and gravidity) recorded with unambiguous units. Reliability was lower for continuous variables that could be recorded with different levels of precision (such as birth weight), those that were occasionally measured more than once, and those that could be measured using more than one measurement technique (such as gestational age). Reducing the number of times records are transcribed, categorising continuous variables, and standardising the techniques used for measuring and recording variables would improve the reliability of both hand-written and computerised data sets.

OPSOMMING

In hierdie studie is die betroubaarheid van handgeskrewe en gerekenariseerde rekords van ge boortedata ondersoek, wat versamel is gedurende die ‘Birth to Ten’ -studie aan die Baragwanath hospitaal in Soweto. Die betroubaarheid van handgeskrewe verloskundige en pasgeboortelike rekords is beoordeel deur duplikaatrekords op ses verskillende verander likes te vergelyk, wat onttrek is uit ses verskillende dele van die betrokke lêers. Die gerekenariseerde rekords se betroubaarheid is beoordeel deur die oorspronklike geskrewe rekord van elke veranderlike te vergelyk met rekords wat beskikbaar is in die hospitaal se gerekenariseerde databasis Hierdie datastelle her vergelykbare vlakke van betroubaarheid getoon, waaruit afgelei kan word dat soortgelyke foute voorkom warmeer data oorgeplaas word vaneen deeivan ’n lêer na ’n ander, en vanaf die lêer na die gerekenariseerde databasis. In albei stelle rekords was die betroubaarheid die hoogste vir die kategoriese veranderlike suigeling se geslag, en vir daardie kontinue veranderlikes (soos moeder se ouderdom en gravida) wat in terme van ondubbelsinmge eenhede gekodeer kan word. Kontinue veranderlikes wat op wisselende vlakke van akkuratheid gemeet word (soos gewig met geboorte), veranderlikes wat soms meer as een keer gemeet is, en veranderlikes wat voigens meer as een metingstegniek bepaal is (soos draagtydsouderdom), was minder betroubaar Deur die aantal kere wat rekords oorgeskryf moet word te verminder, kontinue veranderlikes tat kategoriese veranderlikes te wysig. en tegnieke vir meting en aantekening van veranderlikes te standardiseer, kan die betroubaarheid van sowel handgeskrewe as gerekenariseerde datastelle verbeter word.

OBJECTIVE: To estimate the prevalence of vitamin B12 deficiency in adult South Asian patients. DESIGN: Retrospective chart review. SETTING: Family practice clinic in Toronto, Ont. PARTICIPANTS: Records of 988 South Asian patients. INTERVENTION: Of 1000 randomly selected records, we found 988 charts. From charts with at least one documented B12 level, we extracted data on age, mean corpuscular volume (MCV), hemoglobin and ferritin levels, and diet (if available). Descriptive and analytic statistics were calculated. MAIN OUTCOME MEASURES: Levels of serum B12 and factors associated with low levels of B12. RESULTS: B12 results were documented in 49% of charts; 46% of results showed deficiency. Patients older than 65 and vegetarians were more likely to be B12 deficient. Low serum B12 levels were positively correlated with low hemoglobin and ferritin levels and poorly correlated with low MCV levels. CONCLUSION: Many more South Asian patients than patients in the general population have vitamin B12 deficiency. A vegetarian diet seems a strong risk factor. A single low result, however, might not indicate true B12 deficiency.

Integrated care pathways (ICPs) are being widely adopted in orthopaedic surgery. This study compares the quality of medical notation in an ICP with traditional record keeping. During a 3-month period, 53 total hip replacements (ICP notation) and 30 total knee replacements (traditional notation) were performed. The records of each patient were scrutinised using a standardised scoring system, based on The Royal College of Surgeons of England guidelines on medical record keeping. Each set of records (83) was scored for: admission clerking, subsequent entries, consent form, operation note, and discharge letters. The time taken to retrieve this information was recorded. The overall score for traditional records (mean, 70%) was significantly higher (P = 0.001 ) than for the ICP records (mean, 62%). The mean scores for initial clerking, subsequent entries and consent form were higher in the traditional record group. It took 35% longer to retrieve information from the ICP group (P < 0.001). In this study, the quality of record keeping was higher when using the traditional notation than an established ICP. In both groups, the frequency of omissions was high.

OBJECTIVE: To test three methods of introducing health charts into the medical records of six family medicine units. DESIGN: Quasi-experiment. PARTICIPANTS: The staff physicians and family medicine residents in all six units and the nurses in two units. INTERVENTIONS: Group 1 (minimal intervention): health charts, a user's guide and one training session. Group 2 (intermediate intervention): same intervention as for group 1 plus two feedback sessions at 3 and 6 months. Group 3 (maximum intervention): same intervention as for group 2 plus promotion of the team concept (nurses were included). The intervention phase lasted from September 1987 to August 1988. OUTCOME MEASURES: The frequency with which the health charts were used, the item scores of each preventive care activity and the overall unit scores. Data were gathered through chart audits at baseline and at the end of the intervention phase. RESULTS: The frequency with which the health charts were used varied from 3.9% to 26.9%. The greatest increases in item scores were observed in the use of mammography (20.0%), counselling on lifestyle (19.4%) and breast examination (17.2%). Although the overall improvement in the unit scores was statistically significant (p less than 0.05) the hypothesis of an increasing gradient of effect across the three intervention groups could not be tested because of the variation in scores across the units. CONCLUSION: Health charts and other similar tools are useful; however, they are not sufficient to change practice behaviours. The support of a "champion" on the health care team might well be a determining factor of success for the delivery of preventive services in primary care practice.

Detection and monitoring childhood growth disorders requires the correct use of growth charts. A check on the accuracy of every point plotted on Gairdner-Pearson growth charts of premature infants in a hospital paediatric department was carried out. Errors beyond set limits were recorded. Of 611 points plotted on the growth charts of 50 premature infants who were at least 1 year of age at the time of the study, there were 173 (28.5%) points plotted in error. Altogether 94.7% of the errors occurred when plotting the age along the horizontal (X) axis of the growth chart, irrespective of whether weight, length, or head circumference was being measured. There was no evidence that the errors caused appreciable changes in clinical management. Potential sources of error identified were failure to adjust for prematurity correctly, inaccuracy in calculating age, and the use of the logarithmic scale. These errors could be serious and it is important that there should be greater vigilance in using growth charts. The use of age calculators or improved chart design is recommended. Assessment of the use of other growth charts in different settings is also suggested.

OBJECTIVE

To determine whether feedback from attending physicians to residents about outpatient medical records improves chart documentation and quality of care.

DESIGN

Cross-sectional study with repeated measures.

SETTING

Primary care internal medicine clinic at a metropolitan community hospital.

PATIENT/PARTICIPANTS

Fifteen interns and 20 residents.

INTERVENTION

Attending physicians reviewed at least two charts for each resident on three occasions about 4 months apart and then discussed their findings with the residents.

MEASUREMENTS AND MAIN RESULTS

Explicit criteria defined the extent of chart documentation and the comprehensiveness of care delivery. Attending physicians also made a subjective assessment of the overall quality of care. All results were converted to 0-to-1 scales. From the first to the third period, chart documentation increased from 0.60 to 0.86 (p < .001), but there were no significant changes in the delivery of care or in the subjective assessments of the overall quality of care.

CONCLUSIONS

Both review of residents' outpatient medical records and periodic feedback from attending physicians improve how well medical housestaff document care in the chart.

Pediatric Growth Charts have been used in the pediatric community since 1977. The first growth charts were developed by the National Center for Health Statistics as a clinical tool for health care professionals. The growth charts, revised in 2000, by the Center for Disease Control consists of a series of percentile curves for selected body measurements in children [1]. Capitalizing on the benefits of our Electronic Medical Record (EMR), and as a byproduct of nursing electronic documentation of routine heights, weights, and frontal occipital circumferences, our system plots the routine measurements without additional intervention by the staff. Clinicians can view the graphs online or generate printed reports as needed during routine examination for outpatient or hospitalized care. This abstract outlines the background, design process, programming rules utilized to plot growth curves, and the evaluation of the electronic CDC growth charts in our organization.

Electronic health record (EHR) systems serving pediatric populations typically incorporate growth charts to help healthcare providers monitor children’s growth. Currently, easily implementable growth charts are not available for subpopulations having growth that differs from the population as a whole, such as children with Down syndrome. This manuscript describes an approach for generating subpopulation-specific growth charts meeting requirements for implementation into EHR systems, using as an example weights for children with Down syndrome. Gender-specific growth curves were generated from 2358 weight values obtained from 331 patients with Down syndrome from July 2001 until March 2005. The project generated printable curves and computable data tables formatted according to growth chart standards set forth by the Centers for Disease Control and Prevention to facilitate implementation into EHR systems. This approach will help developers implementing growth charts and provides actual data tables for monitoring growth in children with Down syndrome.

Background

Electronic medical records systems (EMR) contain many directly analyzable data fields that may reduce the need for extensive chart review, thus allowing for performance measures to be assessed on a larger proportion of patients in care.

Objective

This study sought to determine the extent to which selected chart review-based clinical performance measures could be accurately replicated using readily available and directly analyzable EMR data.

Methods

A cross-sectional study using full chart review results from the Veterans Health Administration's External Peer Review Program (EPRP) was merged to EMR data.

Results

Over 80% of the data on these selected measures found in chart review was available in a directly analyzable form in the EMR. The extent of missing EMR data varied by site of care (P < 0.01). Among patients on whom both sources of data were available, we found a high degree of correlation between the 2 sources in the measures assessed (correlations of 0.89–0.98) and in the concordance between the measures using performance cut points (kappa: 0.86–0.99). Furthermore, there was little evidence of bias; the differences in values were not clinically meaningful (difference of 0.9 mg/dL for low-density lipoprotein cholesterol, 1.2 mm Hg for systolic blood pressure, 0.3 mm Hg for diastolic, and no difference for HgbA1c).

Conclusions

Directly analyzable data fields in the EMR can accurately reproduce selected EPRP measures on most patients. We found no evidence of systematic differences in performance values among these with and without directly analyzable data in the EMR.