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Can the decision to operate be judged retrospectively? A study of medical records
J G Jeannot1, J P Vader, F Porchet
1Institute of Social and Preventive Medicine (IUMSP), University of Lausanne Hospital (CHUV), Switzerland.
Objective:
To examine the precision and completeness of information in medical records for evaluating the appropriateness of operative indications for lumbar disc surgery.
Design:
Retrospective review of records.
Setting:
University department of neurosurgery, Switzerland.
Subject:
100 patients.
Interventions:
None.
Main Outcome Measures:
Proportion of pre-defined, detailed appropriateness criteria present in the records. Proportion of cases that could unequivocally be classified as to the appropriateness of the indication for operation.
Results:
The criteria were present and precise for 52 of the items (range 9-90); present but imprecise for 38 of the items, and absent for 10. Because of this imprecision, the appropriateness of only 7 of the operative indications could be unequivocally assessed retrospectively.
Conclusion:
Medical records are of limited use in assessing the appropriate management of care. The process of care should therefore be evaluated prospectively.
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