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Chart review. A need for reappraisal.

L Wu¹, C M Ashton

¹General Medicine Section, Veterans Affairs Medical Center, Houston, Texas 77030, USA.

Evaluation & the Health Professions

|May 7, 1997

Summary

Chart review studies often lack reliability. Enhancing data collection validity requires attention to interrater reliability and supplementary data sources in health care epidemiology and quality assessment research.

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Area of Science:

Health care research methodology
Clinical epidemiology
Quality assessment studies

Background:

Chart review is a common data collection method in health care research.
Concerns exist regarding the reliability and validity of chart review findings.
Previous literature has not sufficiently detailed these imperfections.

Purpose of the Study:

To detail the imperfections of chart review as a data collection method.
To emphasize the issue of reliability in chart review studies.
To assess the reporting of interrater reliability and supplementary data sources.

Main Methods:

Systematic review of 125 journal articles published in 1991-1992.
Articles selected were based principally on chart review findings.
Studies categorized as clinical/health care epidemiology or quality assessment.

Main Results:

Only 8% of epidemiology and 56% of quality assessment studies reported interrater reliability.
44% of epidemiology and 20% of quality assessment studies omitted the number of reviewers.
43% of epidemiology and 28% of quality assessment studies used supplementary data.

Conclusions:

The validity and utility of chart review studies are often compromised.
Improved reporting of interrater reliability is crucial.
Incorporating supplementary data sources can enhance study robustness.

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