PMID- 21303769
OWN - NLM
STAT- MEDLINE
DCOM- 20110725
LR  - 20220409
IS  - 2044-5423 (Electronic)
IS  - 2044-5415 (Linking)
VI  - 20
IP  - 4
DP  - 2011 Apr
TI  - Quality of patient record keeping: an indicator of the quality of care?
PG  - 314-8
LID - 10.1136/bmjqs.2009.038976 [doi]
AB  - 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.
FAU - Zegers, Marieke
AU  - Zegers M
AD  - NIVEL, Netherlands Institute for Health Services Research, Utrecht, The 
      Netherlands. m.zegers@iq.umcn.nl
FAU - de Bruijne, Martine C
AU  - de Bruijne MC
FAU - Spreeuwenberg, Peter
AU  - Spreeuwenberg P
FAU - Wagner, Cordula
AU  - Wagner C
FAU - Groenewegen, Peter P
AU  - Groenewegen PP
FAU - van der Wal, Gerrit
AU  - van der Wal G
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20110208
PL  - England
TA  - BMJ Qual Saf
JT  - BMJ quality & safety
JID - 101546984
MH  - Humans
MH  - Medical Errors/*statistics & numerical data
MH  - Medical Records/*standards
MH  - *Quality Indicators, Health Care
MH  - Retrospective Studies
EDAT- 2011/02/10 06:00
MHDA- 2011/07/26 06:00
CRDT- 2011/02/10 06:00
PHST- 2011/02/10 06:00 [entrez]
PHST- 2011/02/10 06:00 [pubmed]
PHST- 2011/07/26 06:00 [medline]
AID - bmjqs.2009.038976 [pii]
AID - 10.1136/bmjqs.2009.038976 [doi]
PST - ppublish
SO  - BMJ Qual Saf. 2011 Apr;20(4):314-8. doi: 10.1136/bmjqs.2009.038976. Epub 2011 Feb 
      8.