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Related Experiment Videos

Self-report versus medical record functional status.

R B Burns1, M A Moskowitz, A Ash

  • 1Section of General Internal Medicine, Boston University School of Medicine, MA.

Medical Care
|May 1, 1992
PubMed
Summary
This summary is machine-generated.

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Functional status assessment is crucial for hospitalized older adults. Self-report and medical records show significant differences, with both impacting nursing home placement predictions.

Area of Science:

  • Geriatrics
  • Health Services Research
  • Patient Outcomes

Background:

  • Assessing functional status in hospitalized older adults is increasingly recognized as vital.
  • However, the accuracy and completeness of functional status data in medical records are questionable.
  • This study addresses the discrepancies between self-reported and documented functional status.

Purpose of the Study:

  • To compare the accuracy of self-reported functional status with medical record data in hospitalized patients aged 65 and older.
  • To determine the association between functional status data and post-hospital discharge destination, specifically nursing home placement.
  • To evaluate the completeness of functional status documentation in patient medical records.

Main Methods:

  • Data collected from 2,504 elderly patients discharged alive, including self-reported activities of daily living (ADLs) via interview and medical record abstraction.

Related Experiment Videos

  • Functional dependence defined as requiring human assistance for any ADL.
  • Post-discharge follow-up to ascertain discharge location (e.g., nursing home).

    • Main Results:

    • Significant amounts of missing functional status data in medical records, ranging from 20% (bathing) to 50% (dressing).
    • Substantial differences observed in the number of dependencies between self-report (3.2 +/- 1.5) and medical records (2.3 +/- 1.9).
    • Both self-reported and medical record functional status data were independently significant predictors of nursing home discharge (Odds Ratio = 1.6).

    Conclusions:

    • Self-reported and medical record data on functional status for hospitalized older adults differ considerably.
    • Medical record documentation of functional status is often incomplete and may not accurately reflect patient dependency.
    • Despite discrepancies, both data sources independently predict nursing home placement, highlighting the importance of accurate functional status assessment.