To best use the information available in the medical record, one must identify the actual events that led to the final chart. In the simplest case, this means that the patient, or surrogate, told something to someone, often the physician or nurse, who recorded it in the medical record. Because of the retrospective nature of chart review studies, accurately determining how the transfer of information from the patient to the record occurred and what information loss/degradation resulted is usually impossible.
Everyone is familiar with the children's game called “telephone” and how statements can change with retelling. A similar process occurs in recording the medical encounter. One study
- Schwartz RJ
- Boisoneau D
- Jacobs LM
The quantity of cause-of-injury information documented on the medical record: an appeal of injury prevention.
showed that the physician asks enough questions to obtain only 68% of the information available about the mechanism of injury from trauma patients. Of the information obtained, only 67% of it was recorded in the medical record, so less than half of the available information actually was recorded. Differences also existed in the amount of information obtained by level of training; medical students obtained the most information from the patient but recorded the least, and attending physicians obtained the least information from the patient but recorded the most.
- Agius RM
- Lee RJ
- Symington IS
- Riddle HF
- Seaton A
An audit of occupational medicine consultation records.
The identification of mistakes in road accident records. Part 2: Casualty variables.
- 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.
- 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.
- Martie TJ
- Durant H
- Sealy E
Pneumonia: the quality of medical records data.
Do not assume that information obtained directly from patients is always true. For example, limited patient recollection of events can result in recall bias. The longer the time period, the less a patient will remember.
- Hale WA
- Delaney MJ
- Cable T
Accuracy of patient recall and chart documentation of falls.
- Casey R
- Rieckhoff M
- Beebe SA
- Pinto-Martin J
Obstetric and perinatal events: the accuracy of maternal report.
- 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.
Even information that we expect everyone should recall, such as children's birth weight,
- Pyles MK
- Stolz HR
- MacFarlane JW
The accuracy of mothers' reports on birth and developmental data.
Reliability of mothers' reports of birth data.
- Preston SL
- Briceland IL
- Lesar TS
Accuracy of penicillin allergy reporting.
and medication histories,
- Beers MH
- Munekata M
- Storrie M
The accuracy of medication histories in the hospital medical records of elderly persons.
are frequently inaccurate. The ability of patients to recall information varies with patient characteristics, such as age,
Reliability of mothers' reports of birth data.
- Linet MS
- Harlow SD
- Mclaughlin JK
- McCaffrey LD
A comparison of interview data and medical records for previous medical conditions and surgery.
and who did the reporting.
- Tsubono Y
- Fukao A
- Hisamichi S
- Hosokawa T
- Sugawara N
Accuracy of self-report for stomach cancer screening.
- 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.
All of these can cause errors in the data.
Documentation process in the medical record
The medical record has many purposes, but research was not one of them when originally generated. Inaccuracies of the medical record are well known. The method of recording also can affect accuracy. For example, the process of dictation and transcription has been shown to introduce more inaccuracies into the medical record, such as in recording childhood immunizations.
Evaluating the accuracy of transcribed computer-stored immunization data.
However, a dictated and transcribed medical record usually contains more information than handwritten medical records.
- Stueven HA
- Tonsfeldt DJ
- Hargarten KM
- Olson DW
A dictated and transcribed medical record can be cost effective.
Other technologies, such as voice-recognition dictation systems and other keyless entry devices, generally have improved the accuracy and completeness of documentation.
Research review: use of keyless data entry in medical record departments.
- Linn NA
- Rubenstein RM
- Bowler AE
- Dixon JL
Improving the quality of emergency department documentation using the voice-activated word processor: interim results.
A computerized audit of 15,009 emergency department records.
- Nazareth I
- King M
- Haines A
- Rangel L
- Myers S
Accuracy of diagnosis of psychosis on general practice computer systems.
- Chua RV
- Cordell WH
- Emsting KL
- Bock HC
- Nyhuis AW
Accuracy of bar codes vs handwriting for recording trauma resuscitation events.
All charting technologies should be assumed to contain errors until formally evaluated for accuracy. However, electronic charts can also provide opportunities to access large databases for studies.
- Payne TH
- Goroll AH
- Morgan M
- Barnett GO
Conducting a matched-pairs historical cohort study with a computer-based ambulatory medical record system.
Although not the subject of this article, it should be mentioned that registries are often used for archival studies. Disease registries (eg, cancer or trauma registries) were generally created for surveillance and epidemiologic purposes. Their development was usually not intended primarily for research or to replace the medical record. Therefore, if used for purposes other than intended, a potential for bias exists.
- Ing RT
- Baker SP
- Eller JB
- et al.
Injury surveillance systems: strengths, weaknesses, and issues workshop.
- Ribbeck BM
- Runge JW
- Thomason MH
- Baker JW
Injury surveillance: a method for recording E codes for injured emergency department patients.
- Langdorf MI
- Strange G
- Macneil P
Computerized tracking of emergency medicine resident clinical experience.
- Roos LL
- Mustard CA
- Nicol JP
- McLerran DF
- Malenka DJ
- Young TK
- et al.
Registries and administrative data: organization and accuracy.
Diagnoses placed on a discharge summary sheet or a billing form might have biases based on the intended use of the data. Such lists are also used by third-party payers, such as insurance companies and the Centers for Medicare and Medicaid Services. As a result, biases affect what gets documented in this list.
- Hsia DC
- Krushat WM
- Fagan AB
- Tebbutt JA
- Kusserow RP
Accuracy of diagnostic coding for Medicare patients under the prospective-payment system.
For example, The Department of Health and Human Services has agreed that hospitals can record additional diagnoses that “affect patient care, requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increase nursing care or monitoring.”
Other discharge diagnosis problems include indistinct coding, variable thresholds for listing chronic conditions, and reluctance for physicians to record complications.
Accuracy in recorded diagnoses.
Even death certificates, which are controlled by law in all 50 states, have been shown to be inaccurate. The reasons for this vary with disease entity and location but the situation is present in many nations in the world.
- Moussa MA
- Shafie MZ
- Khogali MM
- el-Sayed AM
- Sugathan TN
- Cherian G
- et al.
Reliability of death certificate diagnoses.
- Lapidus G
- Braddock M
- Schwartz R
- Banco L
- Jacobs LM
Accuracy of fatal motorcycle-injury reporting on death certificates.
Finally, the process of coding that occurs with most medical records affects subsequent database creation. This is routinely done by medical records or billing personnel.
Who should abstract medical records? A study of accuracy and cost.
- Dawson-Saunders B
- Mast TA
- Finch WT
- Konrad HR
- Folse JR
Content knowledge and problem-solving skill in reviewing medical charts.
Clinical coding: completeness and accuracy when doctors take it on [see comments].
The coding process is not done for research and can cause problems with identifying study charts. Meeting with the coders can help the researcher best identify the desired subjects.
Abstracting the medical record
The process of reviewing the medical record and abstracting the information to be used for research is one of the last steps in the flow of information in chart review studies. However, before any chart is abstracted for a given research project, the investigator must clearly identify the research question and case definition (which patients you are going to include and exclude), as well as all other important variables in the study. Even retrospective studies need inclusion and exclusion criteria. Once there is a definition of the study cases and variables, they should not be changed during the study. If, after reviewing the initial charts, the definitions need to be altered, the study must re-start at the beginning again with new chart abstraction. Otherwise, study patients would enter using two different criteria, which could introduce significant bias.
Keep accurate records about the charts that are available and those that are missing. Invariably, charts will be missing. If less that 5% of all the charts, it can usually be ignored as a source of bias, especially if the study is large. If 10% are missing, the results may only be 90% accurate, and an effort should be made to determine why. This could cause significant bias. Computerized logs or census data can assist in determining whether the missing charts have a common thread or are missing for a specific purpose.
No matter how diligent, there will always be some charts and individual data items that remain missing. If careful evaluation reveals that the missing items do not represent a pattern that would introduce a significant bias, a decision must be made regarding how to handle the holes in the study database. A number of potential approaches, ranging from averaging only the available data to entirely dropping that chart or group, as appropriate, are possible. Regardless of the process used, it should be established in advance wherever possible and applied consistently throughout the study. Discuss this with an experienced researcher or a statistician.
There are several important issues relating to abstractors. First, they must be qualified. Consistency and completeness are the keys to accurately reviewing charts. When possible, the person actually doing the abstraction of the medical record should not know the purpose of the research; this is called blinding and can be difficult to accomplish. It may involve lying to the abstractors. However, without it, subjective abstraction decisions are prone to bias. Bias also can occur when information must be coded as “missing,” “negative,” or “unsure.”
If the abstraction is done by multiple personnel, consistency is an issue. Differences in technique between individuals must be measured and minimized. More potential biases and errors occur as the information gets transferred from the medical research to the research database. In addition to the coding and categorical errors that can be made, simple transcription errors can always occur when entering data.
Every study should have an operations manual. At every step in the process of information flow and medical record review, the investigator should record what has been done, how, and why. Do not rely on memory. Subsequent publications should describe the study methodology in sufficient detail to allow the reader to, generally, reproduce the study themselves.