Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data.

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23 Citations (Scopus)

Abstract

This paper explores the attributes of quality in recorded clinical encounter data, examines issues in measuring these attributes, and describes a method for measuring two attributes, completeness and correctness. The method is defined in the context of computer-based records and is demonstrated in a pilot study. Videotaped physician-patient encounters and an empiric process of determining a gold standard for content are used. The methodology was found to be feasible. Problems encountered during the pilot study can be remedied.

Original languageEnglish (US)
Pages (from-to)408-412
Number of pages5
JournalProceedings / AMIA ... Annual Symposium. AMIA Symposium
StatePublished - 2001

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abstract = "This paper explores the attributes of quality in recorded clinical encounter data, examines issues in measuring these attributes, and describes a method for measuring two attributes, completeness and correctness. The method is defined in the context of computer-based records and is demonstrated in a pilot study. Videotaped physician-patient encounters and an empiric process of determining a gold standard for content are used. The methodology was found to be feasible. Problems encountered during the pilot study can be remedied.",
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