• No results found

Validity of the Medical Record for Evaluation of Telephone Management

N/A
N/A
Protected

Academic year: 2020

Share "Validity of the Medical Record for Evaluation of Telephone Management"

Copied!
6
0
0

Loading.... (view fulltext now)

Full text

(1)

Validity

of the Medical

Record

for Evaluation

of

Telephone

Management

Pamela

Runge

Wood,

MD

From the University of Texas Health Science Center at San Antonio

ABSTRACT. The purpose of this study was to determine whether the medical record provides accurate

documen-tation of the telephone encounter. The study was a “blinded” comparison of audiotaped telephone

encoun-ters and corresponding medical records; it was carried out in the continuity clinic of a primary care pediatric

resident-training program. During their first month of

rotation through the outpatient department, 17 PL-I

residents received one or two calls made by a “simulated mother” using standardized scripts. Transcripts of these

calls and the corresponding written medical records were rated by an examiner unaware of the resident’s identity. A standardized instrument was used to measure three aspects of performance: General History Taking, Specific

History Taking, and General Management. A percentage

of agreement was calculated for each scale, and rating

scores of audiotapes and written records were compared.

Twenty-seven pairs of audiotape and written

documen-tation were analyzed. The mean percentage of agreement between audiotapes and written records was high: 78%

for General History Taking, 78% for General

Manage-ment, 77% for Specific History Taking. Rating scores of the audiotape and the medical record were significantly correlated for two of the scales: General Management (r

= .55, P < .01) and Specific History Taking (r = .50, P

< .01). Most aspects ofthe telephone encounter were well

documented in the medical record. However, several dis-crepancies were noted when audiotapes and medical rec-ords were compared for the presence of specific items.

With the exception of the Specific History Taking scale,

there was no correlation between the length of the written

record and the percentage of agreement. These data show

that the medical record provides useful information about

adequacy of telephone management. Pediatrics

1989;84:1027-1030; education, telephone management, residency, medical records, quality assurance.

Practicing pediatricians and residents-in-train-ing spend a significant amount of time each day in

Received for publication Aug 25, 1988; accepted Feb 21, 1989. Presented, in part, at the annual meeting of the Ambulatory Pediatric Association, Anaheim, California, April 30, 1987. Reprint requests to (P.R.W.) Dept of Pediatrics, University of

Texas Health Science Center at San Antonio, 7703 Floyd Curl

Dr, San Antonio, TX 78284.

PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the American Academy of Pediatrics.

the telephone management of illness.’ Telephone management impacts on both patient satisfaction

and disease outcome and is an area of potential professional liability risk.2 There are few data, however, concerning how this particular aspect of

medical care can be taught or evaluated. In a recent

survey of 151 pediatric residency training programs, less than one third of training programs (29%) had

a review system or conducted periodic audits of

telephone calls.5 Evaluation of telephone manage-ment is hampered by the fact that calls are often handled in a variety of patient care settings and without formal supervision.

Audiorecordings of telephone encounters provide

firsthand, complete information about the

encoun-ter. However, few training programs audiorecord calls, and the process of reviewing audiotapes or

transcripts of calls is time-consuming and costly. The written medical record is often the only record of what transpired during a telephone encounter.

Failure to record specific instructions given to par-ents may make it difficult to prove that such in-structions were actually provided. Accurate and complete medical record documentation provides protection against allegations of inadequate or

in-appropriate medical care. In addition, the written

medical record may provide a means of evaluating physician performance. Medical record review has been used successfully to evaluate face-to-face doc-tor-patient encounters.6 If telephone calls are ap-propriately documented in the medical record, then

this written documentation may provide useful in-formation about the telephone encounter.

The purpose of this study was to determine whether the medical record provides accurate

doc-umentation ofthe telephone encounter in a resident continuity clinic. The study questions were as fol-lows: (1) Does written documentation of telephone

encounters provide a complete and accurate record of information exchanged? (2) Does completeness of documentation correlate with length of written

(2)

1028

TELEPHONE

MANAGEMENT

METhODS

Procedure

During their first rotation through the outpatient department, 17 PL-I residents were enrolled in the study. Informed consent for recording telephone calls was obtained from each resident before initi-ation of the study. Each resident received one or

two calls from “simulated mothers” during times when the resident was assigned to function as “tele-phone doctor” in the resident continuity clinic.

To minimize chances of detection, calls from simulated mothers were handled in a manner iden-tical with other calls received during a given clinic session. Using standardized scripts, the simulated

mother played the role of a mother caffing the clinic

for advice about her sick child. Two cases were adapted for use: a 6-month-old baby with diarrhea and a 1-year-old child with fever.3 Details of each

case were provided to the simulated mothers who

were instructed not to provide any information that was not specifically requested by the physician. The mother called the clinic and gave the clerk re-quested information regarding her child’s name, age, primary physician, and chiefcomplaint. A

writ-ten message was recorded on a progress note sheet by the clerk, who was unaware of the study, and

given to the resident who subsequently returned the call. All calls were made from the mother’s

home and audiorecorded by the mother for future

scoring. The residents’ written documentation of telephone calls was collected at the end of each clinic day. Audiotapes were transcribed. These transcripts and the corresponding written docu-mentation (medical record) were rated separately by a single trained rater who was unaware of the resident’s identity and study hypotheses. Twelve written medical records (44%) were also scored by

a second rater to establish reliability. A standard-ized rating form was used.

Evaluation

Methods

The standardized rating form was composed of three scales. The General History scale consisted of 11 items of historical information that applied to any telephone encounter. Examples included the chief complaint, duration of symptoms, and overall condition of the child. The General Management scale consisted of six management items thought to

apply to all cases. Examples included providing a tentative diagnosis and giving instructions for home treatment. The Specific History subscale, which was used previously in the study by Perrin and

Goodman,3 consisted of 13 (diarrhea) or 15 (fever) historical items that were specific to a given case. Sample items from the diarrhea Specific History

Taking scale were hydration status and number of stools per day.

Audiotapes and written records were compared in two ways. First, audiotapes and written records

were compared for the presence or absence of each specific item. A percentage of agreement score was calculated for each scale by dividing the number of items for which there was agreement between the

audiotape and the written record by the total num-ber of items. A percentage of agreement score was also calculated for each specific item within each scale. Second, the specific items for each of the three scales were weighted and summed to give a rating score. For each of the three scales, we corn-pared the rating scores of audiotapes and of corre-sponding medical records. Number of minutes spent on the telephone and length of written doc-umentation in words were also calculated.

Data Analysis

Data analysis was performed using Microstat, a statistical software package for microcomputers. Specific analyses included Pearson correlation

coef-ficients and Student’s t test with two-tailed tests of significance.

RESULTS

Twenty-seven pairs of audiotape and correspond-ing written documentation were available for analy-sis, 12 fever scripts and 15 diarrhea scripts. Ten

residents received calls concerning both fever and diarrhea and made a notation in the medical record. Two residents received two calls but medical record documentation could be found for only one call.

Five residents received only one call.

For the fever script, residents spent a mean of 4.5 minutes (SD ±2.2) on the telephone, and their medical record notation was an average of 69.5 words in length (SD ±25.8). Residents spent a mean of 6.6 minutes (SD ±2.3) answering calls about diarrhea, and their medical record documentation was 93.5 words in length (SD ±46.5).

For PL-I residents as a group, the percentage of agreement between audiotapes and medical record documentation was high. The mean percentage of agreement by scale and the range of percentage of agreement for specific items within each scale are shown in Table 1. For example, the General History scale consisted of 11 historical items with a calcu-lated mean agreement of 78%. Although the mean

percentage of agreement between audiotapes and medical record documentation was high, there was

a wide range of agreement (52% to 96%) for specific items.

When audiotapes and medical records were corn-pared for presence of specific items, several

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(3)

TABLE 1.

Agreement Betwee Record (N = 27)*

n Audiotape and Medical

Scale Agreement (%)

General History Taking 78 ± 12 (52-96)

General Management 78 ± 20 (63-96)

Specific History Taking 77 ± 13 (42-100)

* Results are means ± SD with range in parentheses.

ancies were noted. For example, although residents usually asked about medications given to the child with fever (10 of 12 transcripts), they recorded this information in the chart only 50% of the time (5 encounters). For 7 of 12 encounters, residents re-corded a tentative diagnosis in the medical record, but this information was shared with the parent less than half of the time (3 encounters). In 2 additional encounters, a diagnosis was given to the parents verbally but was not recorded in the chart.

For the diarrhea script, information about medi-cations was seldom obtained (4 of 15 encounters) and, even when obtained, was not recorded in the medical record. Although residents often provided the parent with information about the expected course of illness (7 of 15 encounters), this was seldom recorded (2 encounters).

Length of written documentation in words cor-related significantly with percentage of agreement for the Specific History Taking scale (r = .46, P <

.05).

Percentage of agreement for the other scales

was not related to length of the written note. Rating scores of each audiotape transcript and of the corresponding medical record were compared. Audiotape-rating scores were significantly corre-lated with medical record-rating scores for two of the three subscales (Table 2).

Ten matched pairs of fever and diarrhea script telephone encounters were used to evaluate resident performance for all cases. These results are shown in Table 3. Length of medical record documentation in words, General Management percentage of agreement, and Specific History Taking percentage of agreement were significantly correlated for all cases. There were no systematic differences be-tween scripts. Interrater reliability between the study rater and a second rater (n = 12 pairs) was

92%, 85%, and 91% for General History Taking, General Management, and Specific History Taking scales, respectively.

DISCUSSION

In the structured setting of a resident continuity clinic, medical record documentation of telephone encounters by PL-I residents is a useful tool for evaluating telephone encounters. Completeness of documentation was high, as reflected by the high

TABLE 2.

Correlation Betwee

diotape and Medical Record (N Variable

n Rating

= 27) r

Scores of

Au-P Value

General History Taking .30 NS General Management .55 <.01 Specific History Taking .50 <.01

TABLE

3.

Correlation of Variables Acm

ent Scripts (n = 1O)

as Tw o

Differ-Variable r P

No. of words .74 <.05

General History Taking (% agreement) .35 NS General Management (% agreement) .63 <.05 Specific History Taking (% agreement) .74 <.01

* % agreement is the percentage of agreement between

audiotape and medical record.

percentage of agreement between audiotapes and written records.

Although the overall agreement between

audi-otapes and written records was high, there was

variability in the degree to which specific items

were documented. It is not surprising that some

items were recorded more frequently than others. This finding suggests that residents were selective in which specific aspects of the encounter they recorded in the medical record. In a study

compar-ing 51 tape-recorded physician-patient encounters with information written in the medical record,

Zuckerman et al6 found wide variability in recording patterns by specific item, In view of variability in recording, the quality of a telephone encounter

cannot be judged on the basis of the presence or

absence of only a few specific items in the written

record. Rather, several items should be evaluated

to provide a more reliable measure of the process of care.

Discrepancies between what actually transpired during the telephone encounter and what was

re-corded in the medical record may reflect failure to communicate important information to parents. In

our study, residents usually recorded a tentative diagnosis in the medical record of the child with

fever, but this information was rarely shared with

the parent. Failure to provide parents with a

ten-tative diagnosis may both decrease parental

satis-faction with medical care and result in

misunder-standings about appropriate treatment and

follow-up.7’

Length of written documentation was correlated

with percentage of agreement for the Specific

His-tory Taking scale but not for the other scales. It is

not surprising that residents who wrote lengthy notes recorded more specific historical information.

(4)

1030

TELEPHONE

MANAGEMENT

management information recorded did not vary with the length of the note.

Although overall agreement between audiotapes and medical record documentation was high, there

was variability between residents as reflected by

large standard deviations. Variability in recording by individual residents probably contributed to the fmding that rating scores of medical records and audiotapes were only moderately correlated.

Most variables were significantly correlated across the two scripts used in this study. Our

ina-biity to demonstrate consistency of General

His-tory Taking percentage of agreement scores for both scripts may be due, in part, to the small number of pairs available for review. In addition, individual residents may vary the amount of

infor-mation recorded for different types of clinical prob-lems. If a chart review is used to evaluate resident performance in telephone management, it may be advisable to review five or more telephone encoun-ters for each resident.9

This study was performed in the setting of a resident continuity clinic, where telephone calls and medical records were handled in a structured and consistent manner. In addition, we studied PL-I

residents early in their first year of training when

written medical records tend to be lengthy and fairly comprehensive. We do not know whether these findings could be replicated in other, less structured systems or where telephone calls are handled by more experienced physicians.

Because simulated patients were used, we cannot

make any comments about the relationship of

proc-ess, ie, medical record documentation, to outcome of the illness. This relationship could be explored

by evaluating encounters with actual patients and

their subsequent clinical course. Similarly, we did not directly examine the relationship between phy-sicians’ record-keeping patterns and parental un-derstanding of their child’s illness or satisfaction with medical care. These important outcomes of

medical care deserve further study.

SUMMARY

In the setting of a resident continuity clinic,

medical record review provided useful information

about the process of telephone management of ill-ness. Although overall agreement was high, some discrepancies existed between information

ex-changed and information recorded in the medical record. Completeness of written documentation did not consistently correlate with length of documen-tation. Record-keeping patterns were fairly consist-ent for all cases. Further study is necessary to determine whether the study findings can be

ex-tended to other, less structured, settings or to calls

handled by more experienced physicians.

ACKNOWLEDGMENTS

This work was supported, in part, by US Department of Health and Human Services grant 5 D28 PE

16029-03 and by an institutional research grant as part of the National Institutes of Health Biomedical Research Sup-port Grant Program.

The author thanks Dr Ellen Perrin for permission to use her rating instrument. I gratefully acknowledge the

advice of Dr Linda Martin, Dr D. Michael Foulds, and Dr John Littlefield and the assistance of Annie Sanchez and Dalia R. Garcia in manuscript preparation.

REFERENCES

1. Hessel SJ, Haggerty RJ. General pediatrics: a study of

practice in the mid.1960’s. J Pediatr. 1968;73:271-279 2. Strasser PH, Levy JC, Lamb GA, Rosekrans J. Controlled

clinical trial of pediatric telephone protocols. Pediatrics.

1979;64:553-557

3. Perrin EC, Goodman HC. Telephone management of acute pediatric illness. N Engi J Med. 1978;298:130-135

4. Selbst SM, Korin J. The telephone in pediatric emergency

medicine. Pediatr Emerg Care. 1985;1:108-110

5. Wood PR. Pediatric resident training in telephone manage.

ment: a survey of training programs in the United States. Pediatrics. 1986;77:822-825

6. Zuckerman AE, Starfield B, Hochreiter C, Kovasznay B. Validating the content of pediatric outpatient medical . ords by means of tape-recording doctor-patient encounter.

Pediatrics. 1975;56:407-411

7. Korsch BM, Gozzi EK, Francis V. Gaps in doctor.patient

communication, I: doctor-patient interaction and patient

satisfaction. Pediatrics. 1968;42:855-871

8. Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient

communication: patients’ response to medical advice. N EnglJ Med. 1969;280:535-540

9. Maatsch JL, Huang RR, Downing SM, Munger BS. Exam-iner assessments of clinical performance: what do they tell us about clinical competence. Eval Prog Plan.

1987;10:13-17

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(5)

1989;84;1027

Pediatrics

Pamela Runge Wood

Validity of the Medical Record for Evaluation of Telephone Management

Services

Updated Information &

http://pediatrics.aappublications.org/content/84/6/1027

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(6)

1989;84;1027

Pediatrics

Pamela Runge Wood

Validity of the Medical Record for Evaluation of Telephone Management

http://pediatrics.aappublications.org/content/84/6/1027

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1989 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

References

Related documents

Finally, attention should be made to the case of lifetime neighborhood of less than 0.02 (expressed with diamond marker) that corresponds to the neighbors, which did not stop at

provider, to save data costs in your phone bill, you can use a Wi-Fi network to connect to the internet?. Tip: Save new street maps to your phone before a journey,

Our study has excluded the possibility of a large treatment effect of LIUS therapy (i.e. a difference between LIUS therapy and placebo of 35% of patients improving by 50%

To study the deficiency rates of 25(OH) D in mild, moderate, and severe COPD patients, the study reported the deficiency rates of 25(OH)D in COPD patients and included the

Complaints filed with the Title IX Coordinator or the Deputy Title IX Coordinator must be in writing and provide the following information: (i) name and contact information

Keywords : monetary policy, minimum reserves, discount rate, banking system, banking credit, domestic savings, investments, current account balance.. JEL Classification: E21, E22,

This study demonstrated the effect of variable anti-dia- betic treatment strategy on the oxidative stress biomarkers regarding glycemic control and their effect on lipopro-