RT Journal Article
SR Electronic
T1 Quality of patient record keeping: an indicator of the quality of care?
JF BMJ Quality & Safety
JO BMJ Qual Saf
FD BMJ Publishing Group Ltd
SP 314
OP 318
DO 10.1136/bmjqs.2009.038976
VO 20
IS 4
A1 Marieke Zegers
A1 Martine C de Bruijne
A1 Peter Spreeuwenberg
A1 Cordula Wagner
A1 Peter P Groenewegen
A1 Gerrit van der Wal
YR 2011
UL http://qualitysafety.bmj.com/content/20/4/314.abstract
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.