Medical record-keeping and patient perception of hospital care quality

Abstract

A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care.

How to assure the quality of clinical records? A 7-year experience in a large academic hospital

“…However, the reduced completeness in drug therapy items could be a predictor of poor quality of care [ 10 , 11 , 23 ]. These findings are consistent with prior research [ 12 , 18 ] and suggested that further investments and attention should be put on doctors behaviour in order to prevent potentially harmful consequences for patient safety [ 11 , 12 , 23 ]. Despite the results obtained in themes and moments, there is the opportunity to improve performance as far as levels are concerned, achieving a better completeness in the Level 2 -management and Level 3 -re-assessment, pursuing a better quality of care.…”

“…A complete and accurate CR can help achieve safer practices [ 2 ], such as better communication and medication reconciliation, which are common reasons for medical errors worldwide [ 9 – 11 ]. Several authors reported that poor quality of the information in CR may be a predictor of poor quality of care [ 3 , 12 – 16 ], and may be associated with higher rates of adverse patient safety events [ 2 , 15 ]. This is true particularly considering adverse drug events, that may be caused by prescribing error in prescription writing, that involved illegibility, ambiguous abbreviations or lack of important piece of information such as date of prescription, dose or route of administration [ 17 ].…”

“…The rationale for measuring quality improvement and patient safety is the belief that good performance reflects good-quality practice [ 21 ]. CR is one of the most appropriate sources in order to measure and evaluate quality of care [ 2 , 3 , 7 , 12 – 15 ] and the diligence with which information is recorded by professionals in it is an important quality indicator that needs to be evaluated in healthcare organizations [ 2 , 14 , 16 , 22 ]. Indeed, better recording of clinical information leads to better communication between healthcare providers and could contribute to better patient outcomes and safer healthcare [ 2 , 23 ].…”

Association between Electronic Medical Records and Healthcare Quality

“…[ 12 ] No independent associations between patient pain perception scores and documented pain assessments or nutritional disorder screening results were reported. [ 13 ]…”

The Quantitative Study of the Faculty Members Performance in Documentation of the Medical Records in Teaching Hospitals of Mazandaran University of Medical Sciences

“…Daily documentation and maintenance of medical record quality is a crucial issue in orthopaedic surgery ( 1 ). Medical record denotes the main information support used by healthcare providers ( 2 ). Although medical records serve many functions, their primary purpose is to record information about patients and their care ( 3 , 4 ).…”