Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data.

摘要

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.