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Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter
J R Logan1, P N Gorman, B Middleton
1Division of Medical Informatics and Outcomes Research, Oregon Health Sciences University, Portland, OR, USA.
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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