Features of medical records in community practices and their association with preventive service delivery

Sharon M. Weyer, Nancy Konrad, Diane Esola, Meredith A. Goodwin, Kurt C. Stange, Sue Flocke

Research output: Contribution to journalReview article

12 Citations (Scopus)

Abstract

Background: Medical records are important for facilitating the process and quality of care. However, little is known about their current state in primary care practices. This article describes features of medical record systems in diverse practices and examines their association with preventive service delivery rates. Methods: Medical records were reviewed from a consecutive sample of outpatients seen by 198 family physicians in 79 community-based practices in Northeast Ohio. The physicians were participants in a clinical trial designed to increase preventive service delivery. Research nurses performed baseline medical record reviews and used ethnographic field notes and a practice environment checklist to provide global assessments of features of medical records. Results: In 79 practices, 3462 medical records were reviewed. Medical records were rated as highly easy to use in 52% of practices; outpatient visit notes were dictated in 54%. Nine percent of practices grouped individual charts by family. Patient notes were computerized in 1% of practices, although several practices had previously tried and abandoned computerized systems. Flow sheets for immunization, screening, and counseling were present on 71%, 63%, and 16% of charts and were used on 34%, 33%, and 3% of charts, respectively. The presence and use of flow sheets were associated with higher preventive service delivery rates. Conclusion: Medical record organization, completeness, and use vary widely, and computerized records remain rare. The association of flow sheet presence and use with preventive service delivery rates shows the potential importance of medical records for enhancing the process and outcome of patient care.

Original languageEnglish (US)
Pages (from-to)28-33
Number of pages6
JournalMedical care
Volume43
Issue number1
StatePublished - Jan 1 2005
Externally publishedYes

Fingerprint

Medical Records
Outpatients
Quality of Health Care
Family Physicians
Checklist
Counseling
Immunization
Primary Health Care
Patient Care
Nurses
Clinical Trials
Organizations
Physicians
Research

Keywords

  • Community practice
  • Documentation
  • Flow sheets
  • Medical record
  • Preventive service delivery
  • Primary care

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health

Cite this

Weyer, S. M., Konrad, N., Esola, D., Goodwin, M. A., Stange, K. C., & Flocke, S. (2005). Features of medical records in community practices and their association with preventive service delivery. Medical care, 43(1), 28-33.

Features of medical records in community practices and their association with preventive service delivery. / Weyer, Sharon M.; Konrad, Nancy; Esola, Diane; Goodwin, Meredith A.; Stange, Kurt C.; Flocke, Sue.

In: Medical care, Vol. 43, No. 1, 01.01.2005, p. 28-33.

Research output: Contribution to journalReview article

Weyer, SM, Konrad, N, Esola, D, Goodwin, MA, Stange, KC & Flocke, S 2005, 'Features of medical records in community practices and their association with preventive service delivery', Medical care, vol. 43, no. 1, pp. 28-33.
Weyer, Sharon M. ; Konrad, Nancy ; Esola, Diane ; Goodwin, Meredith A. ; Stange, Kurt C. ; Flocke, Sue. / Features of medical records in community practices and their association with preventive service delivery. In: Medical care. 2005 ; Vol. 43, No. 1. pp. 28-33.
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