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Quality of patient record keeping: an indicator of the quality of care?
  1. Marieke Zegers1,
  2. Martine C de Bruijne2,3,
  3. Peter Spreeuwenberg1,
  4. Cordula Wagner1,2,3,
  5. Peter P Groenewegen1,4,
  6. Gerrit van der Wal2,3,5
  1. 1NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
  2. 2EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
  3. 3Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands
  4. 4Utrecht University, Department of Sociology, Department of Human Geography, The Netherlands
  5. 5Netherlands Health Care Inspectorate, Utrecht, The Netherlands
  1. Correspondence to Dr Marieke Zegers, NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands; m.zegers{at}iq.umcn.nl

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.

  • Adverse event
  • patient record
  • record review
  • hospital
  • safety

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Footnotes

  • Funding The Dutch Patient Safety Research Program has been initiated by the Dutch Society of Medical Specialists (in Dutch: Orde van Medisch Specialisten) with financial support from the Ministry of Health, Welfare and Sport. The Program is carried out by EMGO Institute/VU University Medical Centre and NIVEL.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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