Related Experiment Video
Updated: Jan 26, 2026

Orthotopic Left Lung Transplantation in Rats
Published on: July 3, 2025
Incomplete event documentation in medical records of lung transplant recipients
John S Troiani1, Stanley M Finkelstein, Marshall I Hertz
1Medical School, University of Minnesota, Minneapolis, USA.
Context:
The medical record is frequently used in clinical studies as a source of information on illness events experienced by patients; however, it may be incomplete.
Objective:
To estimate the extent of incompletely documented acute bronchopulmonary events in a transplant clinic medical record at a single university medical center, using home monitoring data.
Design, Setting, And Subjects:
Trends in daily home monitoring data were compared to contemporaneous medical record documentation at 150 different times in 30 lung transplant recipients over 45 subject-years.
Outcome Measure:
Proportion of acute bronchopulmonary illness events documented in clinic medical record.
Results:
By using home monitoring data in a new way, we found that 40% of events actually suffered by lung recipients could not be ascertained to have occurred from the clinic medical record alone. All missed encounters occurred away from the transplant clinic, and involved hospitalizations and telephone prescriptions.
Conclusions:
Using the clinic medical record alone to identify acute bronchopulmonary events in lung transplant recipients may result in missing 40% of events. This has important ramifications for studies relying on the medical record for acute event ascertainment in lung transplantation and possibly other chronic diseases.
Related Concept Videos
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
The Fossil Record
Incomplete Dominance
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Methods of Documentation V: CBE
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...

