(Received July 24; revision accepted for publication October 1, 1972.)
ADDRESS FOR REPRINTS: (AM.), Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510.
22
AUDIT
OF
MEDICAL
RECORDS
FROM
PEDIATRIC
SPECIALTY
CLINICS
Alan Meyers, M.D.
From the Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT. The medical records of 500 children
attending pediatric specialty clinics were audited
for the presence of data-base items that were
deemed necessary for comprehensive evaluation
and care. The charts were deficient in the
follow-ing respects: no birthweight (22%), no
gesta-tional age (28%), no immunization record (44%), no nutritional data (53%), no growth chart
(45%), no tuberculin test (73%), and no
com-munication with referring physicians (20%).
Forty-six percent of the records were deficient in
four or more of these items. The findings
dem-onstrate the need for a more structured data-base collection system.
Pediatrics, 51:22, 1973, AUDIT, MEDICAL RECORDS, SPECIALTY CLINICS, DATA COLLECTION.
LThOUCH methodological problems
have hindered attempts at relating
medical records with outcome, audit of
rec-ords is being and has been used as a
mea-sure of health care. The present report rep-resents the result of an audit of pediatric
subspecialty clinic records to determine the
presence or absence of basic data
consid-ered necessary for the delivery of care to
children with one or more chronic diseases
seen at a university medical center.
In spite of the fact that these
subspe-cialty clinics are providing secondary rather
than primary care, they are committed to
complete evaluation and management of
as-sociated psychological, social, economic,
and other medical problems. Furthermore, many families have voiced the expectation
of comprehensive care and do not
under-stand the distinction between primary and
secondary care; this is especially true for
the chronically ill child who is seen
fre-quently and for the inner city child. There-fore, it is appropriate to expect that basic
data about the patient and his family
should be collected on each child being
followed by subspecialists. These data
should facilitate medical care by (1) eluci-dating the effects of the disease on the child and his family or the reverse, e.g., the social
history and the child’s growth chart; (2)
ensuring that basic pediatric care is being
delivered concomitantly with secondary
care, e.g., immunizations and tuberculin
tests; and (3) making clinical correlations
for diagnostic and research purposes, e.g.,
family history and gestational age.
SETTING
The pediatric specialty clinics at this
medical center serve as a source for
refer-rals from physicians in southeastern
Con-necticut as well as for those children
followed by the general pediatric clinic.
Most clinics are staffed by at least one
full-time university faculty member whose
pri-mary research interest lies within that spe-cialty, part-time faculty, fellows in the sub-specialty area, house officers, medical stu-dents, and social workers.
A combined inpatient and outpatient
medical record is filed in chronological
or-der and available through a central hospital
record room. Since 1969, the policy of the
department has been to maintain records in
the problem-oriented manner as described
by Weed.1 The usual clinic retrieval rate for
medical records is approximately 90%.
During the academic year 1970 to 1971, a
total of 4,543 children were seen in pediat-ric specialty clinics.
METHODS
Every fifth kept appointment was
sam-pled between July 1, 1970, to January 1,
1971. Duplications were discarded and
TABLE I
DISTRIBUTION OF DEFICIENCIES
TAI3LE II R:coim DEFICIENCIES Birthweight Gestational age Immunization status Family history Social history Nutritional history Growth chart Tine test Lead level* 44 38 ‘53 43 73 81 ARTICLES 23
peated requests to the record room led to a
retrieval rate of 100% for 500 charts.
Demographic data (age, sex, race,
ad-dress ) were obtained on all patients and
the source of referral, usual source of
medi-cal care, and records of communication
with private practitioners were noted. The
number of specialty and general clinic
ap-pointrnents kept and broken were tabulated
as well as emergency room visits, hospital
admissions, and total hospital days. The use
of problem orientation in the records at the
time of the last visit and the mention of
problems other than that for which they
were being followed were noted.
Prior to audit, eight categories of clinical
data were arbitrarily selected for study on
the basis of generally accepted practice and
standards within the department. No
at-tempt was made to assess data collection
specific to the child’s organic problem, but
it was recognized that one or more of the
eight categories selected might be used by
the clinician in assessing specific diseases,
e.g., growth charts in endocrine clinic.
However, it was felt unlikely that four or
more such items would serve this dual
func-tion.
The following criteria for credit were
de-fined. Scoring was either “present” or
“ab-sent.”
1. Birthweight. Credit given for the ac-tual weight in pounds or kilograms. 2. Gestational Age. Credit given for the
gestational age in weeks, months, for
the words “full term” or “premie,” or
for the abbreviations “TBLC” or
“PBLC.”
3. Immunization Status. Credit given for
an actual listing of immunizations
re-ceived or missing, or for the mention
of any specific immunizing agent
re-gardless of the age of the patient. No
credit was given for expressions such
as “up to date” or “ok.”
4. Family History. Credit is given for a “family tree” listing ages and diseases as well as a listing of family members
-complete or partial. No credit was
given to the expression “no FH of
No. of Clinic Patients Studp
Sample, Total Specially Clinic Jj51t5, 0 Records With Four
or .%f ore items .4bsent, c;
Allergy 59 11.8 11 57
Cardiac 179 35.8 34 43
Collagen 13 .6 ‘1 46
Cy,tic tlbro,i, 6 5t 6 31
Dermatology 6 1. 1 50
Endocrine 17 3.4 4 51
llematology 30 6.4 11 53
G.I. 30 6.4 4 43
Metabolism 35 7.0 9 36
Neurology 56 1l. 9 39
Newborn 10 .0 39
Nephrology 8 5.6 6 49
More than one
specialty clinic Ii . ... 9
ease for which the patient is being
followed.
5. Social History. Credit given for
infor-mation concerning the parents’
occu-pations, marital, financial, or
psycho-social data, e.g., the expression “on
AFDC” received credit while
“non-contrib” did not.
6. Nutritional History. Credit was given
for the mention of a particular food,
feeding pattern, or deficiency, but not for the words “obese,” “thin,” etc. in a
description of the physical status of
the child.
7. Growth Chart. Credit was given if the
child was over 2 years of age and
20 18.6 19.2
15
17.2
14.6
‘C
6.6
4.6
3.4
0 1 2 3 4 5 6 7 8
No. of Items Missing
FIG. 1. Distribution of deficiencies. 24
a
..
8
a .g
U 0 0
0
within two years of the visit there was either a point on the growth chart or a mention of the weight and/or height percentile in the note. If the child was under 2 years, then a six-month period
was used. No credit was given for
height and weight data which are
rou-tinely collected by nurses at each visit and not plotted on a growth chart.
8. TB
Test.
Credit was given for tubercu-lin tests results regardless of date; if the test revealed a positive TB test by history, or a negative test by history within the past year.9.
Lead
Level.
Although it was recog-nized that it is not appropriate toscreen for plumbism on all patients,
the department has established certain criteria (age, residence, pica, or
unex-plained anemia). Credit was given
when the blood lead level or other screening test was done and the results recorded on these selected patients.
Thereafter, the entire medical record was examined. Nursing notes, with the excep-tion of the rare pediatric nurse
practition-ers’ notes were excluded. No attempt was
made to interview the subspecialists for
pa-tient data that they have committed to
memory or maintain in separate files not
ac-cessible to other physicians within the medical center.
RESULTS
The study sample is representative of the total subspecialty clinic population as
shown in Table I. The apparent difference
between the study sample and the hospital statistics for hematology clinic is explained
by the fact that many of these children had
leukemia and were seen weekly and the
method of obtaining the sample excluded
second and subsequent visits.
Analysis of clinic utilization revealed a relatively low broken appointment rate
(7.4%) in specialty clinics as opposed to a
broken appointment rate (23.1%) in the
general pediatric clinic by the same
pa-tients who use that clinic as their primary care resource. A high inpatient utilization
na-ARTICLES 25
ture of the problems that these children
manifest requiring frequent hospitalizations for extended periods of time. In spite of the
fact that the primary care physician was
known in 74% of the children, there was no
record of communication with this
physi-cian in 20% of the charts.
A total of 10,385 clinic visits, 1,653 emer-gency room visits, and the inpatient records
of 5,601 hospital days were reviewed and
the records were deficient as shown in
Table II. Figure 1 shows the distribution of
deficiencies. Forty-six percent of the records
had half or more of the data base items
missing.
Charts of the patients who were hospital-ized were no less deficient, nor were there
any significant differences when the age of
the patient or presence of a primary care
physician were examined. There were,
how-ever, differences between the various clinics
as shown in Table I.
Although the stated policy of the
depart-ment was to use the problem oriented
rec-ord keeping system, 93% of the charts did
not contain a problem list. When the last
note in the chart was examined, the “Weed
system” was not used in 96% of the notes.
However, in 26% of these notes a problem
other than that for which they were
followed was mentioned in the text. This
demonstrates the need for better organiza-tion of the record as discussed by Weed.
DISCUSSION
This study demonstrates a failure in
re-cording of data relevant to general
pediat-ric care in children with chronic diseases
who are followed in a teaching hospital’s
specialty clinics. These deficiencies are
striking in view of faculty commitment to a
comprehensive evaluation in the institution, and in spite of the allocation of social work-ers and psychiatrists.
The findings tend to support the
observa-tions of Duff and Hollingshead2 in a study
of hospitalized adults, as well as
Chamber-lin in a review of outpatient records, that a
majority of university physicians approach
the patient from a disease-oriented focus
and that little emphasis is directed toward comprehensive evaluation and treatment.
Attempts are being made to correct such
deficiencies through the use of medical
rec-ord audits, as well as other “prompting
de-vices” such as the computer, the lecture,
and record review by the chief resident.
However, these attempts have been
mini-mally successful.
Direct observation of the clinics under
study have revealed that some physicians
had more data committed to memory than
what appeared in the record. However, in
view of the rapid turnover of physicians in
a teaching hospital the accurate and
com-plete recording of data appears to be
cru-cial. Furthermore, time-motion studies of
house staff, in progress, support the
impres-sion that 40% to 50% of the patient care
provided by a physician is spent with the
medical record. Thus, in spite of the rather
large investment in time, the physician
de-rives little basic pediatric data from this ac-tivity.
Until the medical record reflects a change in orientation away from a disease-oriented focus, alternative data base collections must be studied. The pediatric nurse practitioner,
with her basic orientation of health
main-tenance and screening offers a possible solu-tion to this problem.
REFERENCES
1. Weed, L. L.: Medical Records, Medical
Educa-tion and Patient Care. Chicago: Year Book
Medical Publishers, Inc., 1970.
2. Duff, R. S., and Hollingshead, A. B.: Sickness
and Society. New York: Harper and Row,
Publishers, Inc., 1968.
