Air Medical Journal
Volume 26, Issue 5 , Pages 206-210 , September 2007

Performing chart review studies

  • Edward A. Panacek, MD, MPH

      Affiliations

    • Edward A. Panacek, MD, MPH, is professor of emergency medicine and clinical toxicology at the UC Davis Medical Center in Sacramento, California.

References 

  1. Schwartz RJ , Jacobs LM . Analysis and comparison of research abstracts at MMS, 1987-1990 . Air Med J . 1992;11:7–11
  2. Gilbert EH , Lowenstein SR , Koziol-Mclain J , Barta DC , Steiner J . Chart reviews in emergency medicine research: Where are the methods? . Ann Emerg Med . 1996;27:305–308
  3. Horwitz RI , Yu ED . Assessing the reliability of epidemiologic data obtained from medical records . J Chron Dis . 1984;37:825–831
  4. Bertelsen J . Who should abstract medical records? A study of accuracy and cost . Evaluation Health Professions . 1981;4:79–92
  5. Leininger L , Harris R , Carey T . An analysis of the quality of medical record reviews in general medicine journals [abstract] . Clin Res . 1992;123:560
  6. Schwartz RJ , Boisoneau D , Jacobs LM . The quantity of cause-of-injury information documented on the medical record: an appeal of injury prevention . Acad Emerg Med . 1995;2:98–103
  7. Agius RM , Lee RJ , Symington IS , Riddle HF , Seaton A . An audit of occupational medicine consultation records . Occup Med . 1994;44:151–157
  8. Austin K . The identification of mistakes in road accident records. Part 2: Casualty variables . Accid Anal Prev . 1995;27:277–282
  9. Bairstow BM , Burke V , Beilin IJ , Deutscher C . Inadequate recording of alcohol drinking, tobacco-smoking and discharge diagnosis in medical in-patients: failure to recognize risks including drug interactions . Med Educ . 1993;27:518–523
  10. Kennedy GT , Stem MP , Crawford MH . Miscoding of hospital discharges as acute myocardial infarction: implications for surveillance programs aimed at elucidating trends in coronary artery disease . Am J Cardiol . 1984;53:1000–1002
  11. Martie TJ , Durant H , Sealy E . Pneumonia: the quality of medical records data . Med Care . 1987;25:20–24
  12. Hale WA , Delaney MJ , Cable T . Accuracy of patient recall and chart documentation of falls . J Am Board Fam Pract . 1993;6:239–242
  13. Casey R , Rieckhoff M , Beebe SA , Pinto-Martin J . Obstetric and perinatal events: the accuracy of maternal report . Clin Pediatr . 1992;31:200–204
  14. Tilley BC , Barnes AB , Bergstralh E , Labarthe D , Noller KL , Colton T , et al.   A comparison of pregnancy history recall and medical records: implications for retrospective studies . Am J Epidemiol . 1985;121:269–281
  15. Pyles MK , Stolz HR , MacFarlane JW . The accuracy of mothers' reports on birth and developmental data . Child Dev . 1935;6:165–176
  16. Oates RK , Forrest D . Reliability of mothers' reports of birth data . Aust Paediatr J . 1984;20:185–186
  17. Preston SL , Briceland IL , Lesar TS . Accuracy of penicillin allergy reporting . Am J Hosp Pharm . 1994;51:79–84
  18. Beers MH , Munekata M , Storrie M . The accuracy of medication histories in the hospital medical records of elderly persons . J Am Geriatr Soc . 1990;38:1183–1187
  19. Linet MS , Harlow SD , Mclaughlin JK , McCaffrey LD . A comparison of interview data and medical records for previous medical conditions and surgery . J Clin Epidemiol . 1989;42:1207–1213
  20. Tsubono Y , Fukao A , Hisamichi S , Hosokawa T , Sugawara N . Accuracy of self-report for stomach cancer screening . J Clin Epidemiol . 1994;47:981–988
  21. Bondy ML , Strom SS , Colopy MW , Brown BW , Strong Le . Accuracy of family history of cancer obtained through interviews with relatives of patients with childhood sarcoma . J Clin Epidemiol . 1994;47:89–96
  22. Wilton R , Pennisi AJ . Evaluating the accuracy of transcribed computer-stored immunization data . Pediatrics . 1994;94:902–906
  23. Stueven HA , Tonsfeldt DJ , Hargarten KM , Olson DW . A dictated and transcribed medical record can be cost effective . J Am Record Assoc . 1991;62:37–40
  24. Patrikas EO . Research review: use of keyless data entry in medical record departments . Top Health Inform Manage . 1993;14:69–76
  25. Linn NA , Rubenstein RM , Bowler AE , Dixon JL . Improving the quality of emergency department documentation using the voice-activated word processor: interim results . Proc Annu Symp Comput Appl Med Care . 1992;772–776
  26. Holbrook J , Aghababian R . A computerized audit of 15,009 emergency department records . Ann Emerg Med . 1990;19:139–144
  27. Nazareth I , King M , Haines A , Rangel L , Myers S . Accuracy of diagnosis of psychosis on general practice computer systems . Br Med J . 1993;307:32–34
  28. Chua RV , Cordell WH , Emsting KL , Bock HC , Nyhuis AW . Accuracy of bar codes vs handwriting for recording trauma resuscitation events . Ann Emerg Med . 1993;22:1545–1550
  29. Payne TH , Goroll AH , Morgan M , Barnett GO . Conducting a matched-pairs historical cohort study with a computer-based ambulatory medical record system . Comput Biomed Res . 1990;23:455–472
  30. Ing RT , Baker SP , Eller JB , et al.   Injury surveillance systems: strengths, weaknesses, and issues workshop . Public Health Rep . 1985;100:582–586
  31. Ribbeck BM , Runge JW , Thomason MH , Baker JW . Injury surveillance: a method for recording E codes for injured emergency department patients . Ann Emerg Med . 1992;21:37–40
  32. Langdorf MI , Strange G , Macneil P . Computerized tracking of emergency medicine resident clinical experience . Ann Emerg Med . 1990;19:764–773
  33. Roos LL , Mustard CA , Nicol JP , McLerran DF , Malenka DJ , Young TK , et al.   Registries and administrative data: organization and accuracy . Med Care . 1993;31:201–212
  34. Hsia DC , Krushat WM , Fagan AB , Tebbutt JA , Kusserow RP . Accuracy of diagnostic coding for Medicare patients under the prospective-payment system . N Engl J Med . 1988;318:352–355
  35. In: Coding Clinic for ICD-9-CM . 7: Chicago, IL: American Hospital Association Division of Quality Control Management; 1990;p. 13
  36. Jencks SF . Accuracy in recorded diagnoses . JAMA . 1992;267:2238–2239
  37. Moussa MA , Shafie MZ , Khogali MM , el-Sayed AM , Sugathan TN , Cherian G , et al.   Reliability of death certificate diagnoses . J Clin Epidemiol . 1990;43:1285–1295
  38. Lapidus G , Braddock M , Schwartz R , Banco L , Jacobs LM . Accuracy of fatal motorcycle-injury reporting on death certificates . Accid Anal Prev . 1994;26:535–545
  39. Bertelsen J . Who should abstract medical records? A study of accuracy and cost . Evaluation Health Professions . 1981;4:79–92
  40. Dawson-Saunders B , Mast TA , Finch WT , Konrad HR , Folse JR . Content knowledge and problem-solving skill in reviewing medical charts . Med Educ . 1984;18:31–35
  41. Yeoh C , Davies H . Clinical coding: completeness and accuracy when doctors take it on [see comments] . BMJ . 1993;306:972

 Editors' note: This article is the eighth in a multipart series designed to improve the knowledge base of readers, particularly novices, in the area of clinical research. A better understanding of these principles should help in reading and understanding the application of published studies. It should also help those involved in beginning their own research projects.

PII: S1067-991X(07)00160-5

doi: 10.1016/j.amj.2007.06.007

Air Medical Journal
Volume 26, Issue 5 , Pages 206-210 , September 2007

Article Tools

* Image Usage & Resolution