Medicine and Health Sciences Commons^™

Quality And Correlates Of Medical Record Documentation In The Ambulatory Care Setting, Ken Kleinman, Carlos Soto, Steven Simon

Public Health Department Faculty Publication Series

Background

Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record.

Methods

We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians) at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information …