Evaluation of the quality of filling out medical records in a hypertension consultation
Tache, A.; Chatellier, G.; Ménard, J.
Archives des Maladies du Coeur et des Vaisseaux 90(8): 1189-1193
1997
ISSN/ISBN: 0003-9683 PMID: 9404434 Document Number: 476796
The aim of the study was to evaluate the completion of medical records of a hypertension clinic and to compare standardized computerized records versus standard medical records. The medical records of 163 consecutive hypertensive patients attending at the Broussais hospital hypertension clinic between December 1995, 6th and January 1996, 21st were checked. At the last visit, the patients were attended by 16 physicians working in 4 different teams. The medical data were recorded by physicians in the computerized system called ARTEMIS in 120 patients and in standard structured forms in 43 patients. The patients notes were checked to see if 9 clinical items were recorded at the first visit (V1), at the visit before last (V2) and at the last visit (V3). The overall completion rate was high at V1 (92.2%) and significantly decreased at follow-up visits (82.6% at V2 and 83.2% at V3). The completion rate was significantly higher in the computerized records than in the standard notes: 95.8% vs 82.2% at V1, 91.9% vs 56.3% at V2 and 91.6% vs 59.7% at V3. During follow-up (V2 vs V1), a significant decrease in the completion rate of 6 items was observed in the standard notes (tobacco use, alcohol consumption, physical activity, compliance to treatment, body weight, manual blood pressure measurement). In the computerized records, only physical activity completion rate decreased. In conclusion, the computer may help to increase the quality of the medical records as reflected by the completion rate of items related to hypertension care.