International Journal of Health Care Quality Assurance Medical record-keeping and patient perception of hospital care quality Van Mô Dang Patrice François Pierre Batailler Arnaud Seigneurin Jean-Philippe Vittoz Elodie Sellier José Labarère
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Medical record-keeping and patient perception of hospital care quality Van Moˆ Dang Department of Medicine, Division of Geriatrics, Grenoble University Hospital, Grenoble, France, and
Patrice Franc¸ois, Pierre Batailler, Arnaud Seigneurin, Jean-Philippe Vittoz, Elodie Sellier and Jose´ Labare`re
Medical record-keeping
531 Received 2 February 2013 Revised 4 February 2014 Accepted 23 March 2014
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Quality of Care Unit, Grenoble University Hospital, Grenoble, France Abstract Purpose – Medical record represents the main information support used by healthcare providers. The purpose of this paper is to examine whether patient perception of hospital care quality related to compliance with medical-record keeping. Design/methodology/approach – The authors merged the original data collected as part of a nationwide audit of medical records with overall and subscale perception scores (range 0-100, with higher scores denoting better rating) computed for 191 respondents to a cross-sectional survey of patients discharged from a university hospital. Findings – The median overall patient perception score was 77 (25th-75th percentiles, 68-87) and differed according to the presence of discharge summary completed within eight days of discharge (81 v. 75, p ¼ 0.03 after adjusting for baseline patient and hospital stay characteristics). No independent associations were found between patient perception scores and the documentation of pain assessment and nutritional disorder screening. Yet, medical record-keeping quality was independently associated with higher patient perception scores for the nurses’ interpersonal and technical skills component. Research limitations/implications – First, this was a single-center study conducted in a large full-teaching hospital and the findings may not apply to other facilities. Second, the analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, the authors could not investigate whether electronic medical record contributed to better compliance with recording standards and eventually higher patient perception scores. Practical implications – Because of the potential consequences of poor recording for patient safety, further efforts are warranted to improve the accuracy and completeness of documentation in medical records. Originality/value – A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care. Keywords Patient satisfaction, Documentation, Hospitals, Medical records, Quality standards Paper type Research paper
Introduction Although medical records serve many functions, their primary purpose is to record information about patients and their care (Huston, 2004; Mann and Williams, 2003). Medical records provide clinical staff caring for patients with information needed to deliver optimal care in present or future hospital episodes (Carpenter et al., 2007). Medical-record structure and content have attracted interest for decades (Siegler, 2010). Yet medical record-keeping quality is highly variable (Daucourt and Michel, 2003; Mann and Williams, 2003; Osborn et al., 2005). Medical record and communication standards have been developed in North America and Europe (Royal College of
International Journal of Health Care Quality Assurance Vol. 27 No. 6, 2014 pp. 531-543 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-06-2013-0072
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Physicians, 2008a, b; Wood, 2001). Adopting such standards has benefits including completeness and accuracy (Mann and Williams, 2003; Martin, 1992), better communication between clinical care providers (Mann and Williams, 2003) and decreased adverse events (Zegers et al., 2011). Few studies report a link between sub-optimal medical records, care processes and clinical outcomes for patients with specific conditions (Dunlay et al., 2008) and none investigate the potential association between medical-record keeping and patients’ hospital care perceptions. This study aimed to determine whether patient perceptions are related to medical-record quality. Specifically, we hypothesized that higher compliance with medical record-keeping standards were observed for patients reporting higher perception scores. If such an association is found then patient satisfaction with care might be an incentive for improving medical records. Methods Study design We merged original data from a nationwide medical-record audit with responses to a cross-sectional university hospital patient survey. Individual-level compliance with medical-record standards were linked to respondent perception scores via hospital identifiers. Because the two studies were designed and conducted independently, fewer patients appeared in both samples. To increase our sample size, we elected to audit additional medical records, which were randomly selected among the cross-sectional survey respondents. Study site Grenoble University Hospital is a full-teaching hospital with 1,347 acute-care beds serving a predominantly urban population (450,000). It also serves as the regional referral centre for the French Northern Alps. Hospital data show 58,412 acute-care stays, with a 6.7 days mean stay in 2010. Patient hospital care quality perception In total, 1,500 patients discharged consecutively from acute-care departments were selected in April 2010 (Batailler et al., 2014). Medical, surgical or obstetrics and gynecology inpatients staying more than one day were eligible if they were discharged alive to home or to a nursing home. Patients transferred to other acute care hospitals and those discharged to post-acute care facilities were not eligible. There was no diagnostic limitation to patient selection. The patients’ care quality perceptions were collected using a standardized survey instrument (Labarere et al., 2001), which included 29 items covering six key hospital care quality components: physician and nurse interpersonal and technical skills, information, continuity, convenience and living arrangements (Appendix 1). Each item was rated on a four-point Likert scale ranging from strongly disagree (1) to strongly agree (4). The survey instrument also included an overall satisfaction item and two items dealing with patient’s intent to recommend the hospital and to return to the hospital for care. The questionnaire was mailed to patients within two to four weeks of discharge along with a pre-paid envelope, a letter guaranteeing patient confidentiality and encouraging participation. A follow-up letter was sent to non-respondents two weeks later. For each patient, we computed six subscale scores, each corresponding to a hospital care quality component and an overall score based on his/her 29 item ratings. Each subscale score was computed as the mean of the individual items constituting the corresponding
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component. Subscale and overall scores ranged between 0 and 100; higher scores denoting better ratings. Subscale scores were coded as missing if more than half the corresponding items had omitted values. Questionnaires with more than six missing values (i.e. an overall proportion higher than 20 percent) were excluded from the analysis; the same strategy used in the original survey instrument’s development and validation (Labarere et al., 2004). Medical-record audit The French agency for healthcare quality (Haute autorite´ de sante´) requires hospital staff to audit medical record and discharge summary structure and content annually (Couralet et al., 2013). In 2010, 354 patients with stays longer than one day were randomly selected among the computerized discharge summaries recorded in our hospital administrative database. In total, 80 hospital stays were sampled to comply with the national audit requirements and 274 additional hospital stays were appraised for local convenience. We examined electronic and paper medical records and collected data using a centralized password-secured web site. The audit tool and help notes had been developed, pre-tested and assessed for inter-rater reliability during a pilot study (Corriol et al., 2008). The tool comprised 75 items and assessed overall medical-record keeping, pain assessment, nutritional disorder screening and discharge summary timeliness and completeness (Appendix 2). The overall medical-record score comprised ten items while the three other standards were binary. Because each standard yielded specific exclusion criteria, audited medical-record numbers varied across standards. Statistical analysis Categorical variables were reported as numbers and percentages, and continuous variables as median, 25th and 75th percentiles. In univariable analysis, differences in overall medical record-keeping score according to patient and hospital stay characteristics were compared using the non-parametric Kruskal-Wallis test. Pain assessment, nutritional disorder screening and timely discharge summary, according to patient and hospital stay characteristics, were analyzed using the w2 or Fisher exact test. We performed multivariable quantile regression analysis (Austin et al., 2005) to examine the independent associations between median patient perception scores and compliance with standards for overall medical-record keeping, pain assessment documentation, nutritional disorder screening documentation and discharge summary timeliness and completeness, respectively. To account for potential confounding by patient and hospital stay characteristics, the models were adjusted for age, gender, surgical procedure and length of stay (LoS). Patients enrolled in the two original studies determined the sample size and no a priori sample size calculation could be performed for this analysis. Two-tailed p-values o0.05 were considered statistically significant. All analyses were performed using Stata version 11.0 (Stata Corporation, College Station, TX, USA). This survey received the French Data Protection Agency’s (commission nationale de l’informatique et des liberte´s, Paris, France) approval. Results Overall, 870 of the 1,500 surveyed patients returned a questionnaire, yielding a 58 percent participation rate. Data collected from the medical record-keeping audit were available for 204 respondents. After excluding nine medical records and four survey questionnaires owing to exclusion criteria, the final sample was 191 patients.
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The median age for all patients was 58 years, 95 (49.7 percent) were female and 28 (14.7 percent) underwent a surgical procedure (Table I). The medical records included electronic and paper documentation for 154 patients (80.6 percent), and paper documents only for 37 patients (19.4 percent). The median overall medical-record quality score was 80/100, with standards compliance ranging from 46.7 percent for discharge medication order to 100 percent for delivery notes (Table II). Pain assessment and nutritional disorder screening documentation prevalence was 55.0 and 74.1 percent, respectively. A discharge summary was found in 117 (61.3 percent) medical records and was completed within eight days following discharge in 72 records (37.7 percent). Compliance with recording standards varied according to age and gender (overall medical-record quality score), surgical procedure (timely discharge summary completion, pain assessment and nutritional disorder screening documentation) and LoS (overall medical record-keeping quality score, timely discharge summary completion and pain assessment documentation) (Table III).
Characteristics
Table I. Patient and hospital characteristics
Age, ya Female gender, n (%) Education level lower than high school, n (%)b Admission to an emergency department observation unit, n (%) Admission to the maternity ward, n (%) Transfer to an intensive care unit within two days of admission, n (%) Surgical procedure, n (%) Discharge to another hospital, n (%) Length of stay, da
58 95 43 71 8 10 28 2 5
(42-73) (49.7) (22.5) (37.2) (4.2) (5.2) (14.7) (1.0) (4-9)
Notes: aData are given as median (25th-75th percentiles). bValues were missing for education level (n ¼ 12)
Standards
Table II. Compliance with medical record-keeping standards
N ¼ 191
Overall medical record-keeping score, median (25th-75th percentiles)a 1. Presence of hospital admission entry (clerking), n (%) 2. Complete hospital admission entry (clerking), n (%) 3. Complete medication orders, n (%) 4. Presence of surgical or invasive procedure notes, n (%) 5. Presence of delivery notes, n (%) 6. Complete anesthetic record, n (%) 7. Complete blood transfusion record, n (%) 8. Complete discharge medication order, n (%) 9. Complete discharge summary, n (%) 10. Medical record structured and organized, n (%) Pain assessment documentation, n (%) Nutritional disorder screening documentation, n (%) Timely discharge summary completion, n (%)
N ¼ 191 80 178 149 138/190 38/40 6/6 31/41 11/12 79/169 117 173 105 66/89 72
(60-88) (93.2) (78.0) (72.6) (95.0) (100.0) (75.6) (91.7) (46.7) (61.3) (90.6) (55.0) (74.1) (37.7)
Note: aThe medical record-keeping score was computed based on compliance with ten standards and ranged between 0 and 100, with higher scores denoting better compliance (see Methods)
67 (57-88) 67 (50-83) 83 (67-87) 86 (80-100)
80 (60-100) 83 (75-88) o0.001
0.25
19/47 19/55 28/44 39/45
(40.4) (34.5) (63.6) (86.7)
81/163 (49.7) 24/28 (85.7)
68/135 (50.4)
75 (60-88)
48/95 (50.5) 57/96 (59.4)
24/53 (45.2) 31/60 (51.7) 50/78 (64.1)
28/44 (63.6)
0.17
o0.001
0.04
Pain assessment documentation, n (%)
83 (67-100)
67 (50-83) 83 (67-100)
67 (60-88) 73 (50-86) 83 (67-100)
p
Note: aValues are given as median (25th-75th percentiles)
Age, y o45 45-64 X65 Gender Female Male Education level Lower than high school High school or higher Surgical procedure No Yes Length of stay, d p3 4-5 6-9 49
Characteristics
Overall medical record-keeping scorea
o0.001
o0.001
0.12
0.22
0.09
p
9/11 20/33 20/26 17/19
(81.8) (60.6) (76.9) (89.5)
47/69 (68.1) 19/20 (95.0)
47/61 (77.0)
16/25 (64.0)
30/44 (68.2) 36/45 (80.0)
16/19 (84.2) 23/34 (67.6) 27/36 (75.0)
Nutritional disorder screening documentation, n (%)
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0.13
0.02
0.21
0.20
0.45
p
13/47 15/55 23/44 21/45
(27.7) (27.3) (52.3) (46.7)
56/163 (34.4) 16/28 (57.1)
49/135 (36.3)
21/44 (47.7)
33/95 (34.7) 39/96 (40.6)
17/53 (32.1) 23/60 (38.3) 32/78 (41.0)
Timely discharge summary completion, n (%)
0.02
0.02
0.18
0.40
0.58
p
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Table III. Medical record-keeping according to patient baseline characteristics
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The median overall patient perception score was 77 (Table IV), with median subscale scores ranging from 75 for the information and physician interpersonal and technical skills components to 83 for the care continuity component (Table V). In multivariable analysis adjusting for patient and hospital stay characteristics, timely discharge summary was the only medical record-keeping standard associated with higher overall patient perception score (Table IV). No subscale patient perception score differed according to medical record-keeping standards, excepting nurses’ interpersonal and technical skills score, which was related to overall medical record-keeping score (Table V). Although pain assessment documentation was associated with a higher patient-percentage very or fairly satisfied with pain control (96.8 (92/95) v. 84.1 percent (58/69), p ¼ 0.004), this difference did not remain significant after adjusting for covariates. Overall, 172 patients (90.0 percent) were very or fairly satisfied with hospital care. Higher overall medical record-keeping scores were observed in very or fairly satisfied patients (median, 81 (60-88) v. 67 (60-67), p ¼ 0.04). Regarding behavioral intentions, 161 patients (84.3 percent) reported that they would likely or very likely recommend the hospital and return to the hospital for care, with no differences according to compliance with recording standards. Discussion We found limited evidence supporting a potential relationship between patient hospital care perception and compliance with medical record-keeping standards. Overall, perceptions related only to the discharge summary timeliness and completeness. No independent associations were observed between patient perception components and compliance with recording standards other than a link between overall medical-record keeping and nurses’ interpersonal and technical skills. Consistent with prior research, we identified low overall medical record-keeping quality (Gabbay and Layton, 1992; Mann and Williams, 2003), pain assessment and nutritional disorder screening (Gabbay and Layton, 1992) and discharge summary completion (Hansen et al., 2011). Because the medical record represents the main Standards
Table IV. Overall patient hospital care quality perception score according to medical-record keeping
All patients Overall medical record-keeping score p80 480 Pain assessment documentation No Yes Nutritional disorder screening documentation No Yes Timely discharge summary completion No Yes
Overall perception of hospital care quality scorea pb 77 (68-87)
– 0.86
76 (64-84) 79 (71-90) 0.73 77 (65-83) 78 (70-91) 0.80 80 (73-86) 79 (68-91) 0.03 75 (64-84) 81 (73-90)
Notes: aData are given as median (25th-75th percentiles). Patient perception scores range between 0 and 100, with higher scores denoting better rating. bp-values were adjusted for age, gender, surgical procedure, and length of stay
75 (58-92) 83 (67-92)
92 (67-92) 75 (58-92)
71 (58-92) 75 (67-92)
75 (58-92) 75 (67-92)
78 (62-93) 86 (76-95) Physicians’ interpersonal and technical skills 75 (67-92)
86 (71-95) 86 (67-95)
77 (67-93) 86 (71-95)
78 (67-93) 86 (74-95)
Nurses’ interpersonal and technical skills 81 (67-95)
0.54
0.54
0.50
pb – 0.78
0.23
0.95
0.23
pb – 0.04
78 (61-89) 83 (67-94)
78 (67-94) 83 (72-94)
78 (61-89) 83 (67-92)
78 (61-89) 83 (67-94)
67 (50-92) 75 (67-92) Living arrangements 78 (67-89)
83 (67-92) 75 (67-92)
67 (55-92) 75 (67-92)
75 (50-92) 75 (67-92)
Information 75 (58-92)
0.05
0.06
0.37
pb – 0.21
0.36
0.21
0.38
pb – 0.70
Perception of hospital care quality scorea
67 (58-83) 75 (67-89)
75 (67-92) 75 (58-89)
75 (67-83) 75 (62-89)
67 (58-83) 75 (67-89)
Convenience 78 (67-89)
75 (58-92) 83 (67-92)
76 (67-92) 83 (67-92)
75 (58-92) 83 (67-92)
75 (58-92) 83 (67-92)
Continuity of care 83 (67-92)
0.36
0.37
0.18
pb – 0.08
0.16
0.80
0.14
pb – 0.26
Notes: aData are given as median (25th-75th percentiles). Patient perception scores ranged between 0 and 100, with higher scores denoting better rating. b p-values were adjusted for age, gender, surgical procedure and length of stay
All patients Overall medical record-keeping score p80 480 Pain assessment documentation No Yes Nutritional disorder screening documentation No Yes Timely discharge summary completion No Yes
All patients Overall medical record-keeping score p80 480 Pain assessment documentation No Yes Nutritional disorder screening documentation No Yes Timely discharge summary completion No Yes
Standards
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Table V. Subscale patient hospital care quality perception scores according to medical–record keeping
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information for healthcare providers, these findings imply potentially harmful consequences for patient safety. Accordingly, higher adverse event rates are associated with poor information recorded in medical charts (Zegers et al., 2011). Although speculative, a potential explanation for the association between medical-record keeping and nurses’ skills scores is that the nurses who document hospital records more thoroughly may also have better interpersonal skills, leading to higher patient perception. Indeed, patient information recorded in hospital chart likely reflects the interaction between healthcare providers and the patient (Solomon et al., 2000). Yet, this hypothesis is partly contradicted by our failure to show a similar association involving physician interpersonal and technical skills. It is also possible that medical-record keeping and nurses’ interpersonal and technical skills have a common origin in safety culture and work environment. On one hand, medical record-keeping quality is part of the hospital work environment besides other aspects like physician-nurse relations, nurse participation in decision making and organizational priorities on care quality. On the other hand, consistent associations between patient hospital care ratings, nurse work environment and safety culture have been reported across western countries (Aiken et al., 2012). In this context, that patients with higher overall medical record-keeping scores were more likely to be satisfied with their hospital stay was expected, since nursing care perceptions strongly influences patient satisfaction (Leiter et al., 1998). Interestingly, an independent association was found between overall patient hospital-care perception and discharge summaries completed within eight days post discharge. This finding accords with studies reporting that deficits in information transfer between hospital-based and primary care physicians at discharge have the potential to negatively affect continuity and safety (Kripalani et al., 2007). The weak association between patient perception and pain assessment documentation was unexpected. Presumably, patients with documented pain assessment would report higher perception scores for nurse interpersonal and technical skills, since this subscale comprised an individual item relating to pain control. However, no independent association was observed between pain assessment documentation and patient-reported pain control in our study. This observation may mirror a gap between objectively documented pain assessment and patient satisfaction with pain control. Although its determinants are not fully understood, patient satisfaction stems from the discrepancy between patient expectations and perceived experience, which may differ from actual experience. Patient-reported pain management procedures is associated with pain relief (Bovier et al., 2004) but complex relationships exist between patient satisfaction with pain management and objective pain level measures, delayed analgesia and pain relief (Hanna et al., 2012; Kelly, 2000). There are several potential explanations for the modest relationship between compliance with medical record-keeping standards and patient hospital care quality perceptions. First, our data represent medical record documentation rather than observing care directly. Substantial disagreement has been previously demonstrated between medical record and direct observation, with the potential for chart abstraction underestimating care quality (Chisholm et al., 2008; Luck et al., 2000; Stange et al., 1998). Conversely, adequate care may be documented in medical records despite providing inadequate care, in an attempt to comply with regulatory standards (Hansen et al., 2011). Second, only modest associations exist between technical care and patient experience (Jha et al., 2008; Sack et al., 2011). Indeed, patients may rely on
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peripheral elements such as comfort, emotional support and friendliness because they do not feel competent to evaluate technical skills (Luxford, 2012). Third, we cannot say that our survey instrument was valid (Batailler et al., 2014), although this was unlikely. We used a self-administered French-language questionnaire developed according to psychometric theory that demonstrated satisfactory validity and reliability (Labarere et al., 2001). Our study has limitations; first this was a single-centre study conducted in a large teaching hospital and the findings may not apply to other facilities. Second, the sample size was determined by patients enrolled in the satisfaction survey and the medical-record audit. Hence, our analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, a recent study reported a positive association between hospital electronic health records and patient satisfaction (Kazley et al., 2012). Because the medical records were hybrid, including electronic and paper documents for most patients enrolled in our study (80.6 percent), we could not investigate whether electronic medical records contribute to better compliance with recording standards and eventually higher patient scores. However, computerized documentation also has specific drawbacks, including unintended copying and pasting. Conclusions We found only weak associations between compliance with medical-record keeping and patient care quality perceptions. It remains unclear whether these findings result from a failure to provide or to document adequate care. Because poor recording has consequences for patient safety, further efforts are warranted to improve medicalrecord accuracy and completeness. References Aiken, L.H., Sermeus, W., Van Den Heede, K., Sloane, D.M., Busse, R., Mckee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L. and Kutney-Lee, A. (2012), “Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States”, British Medical Journal, Vol. 344, p. e1717. Austin, P.C., Tu, J.V., Daly, P.A. and Alter, D.A. (2005), “The use of quantile regression in health care research: a case study examining gender differences in the timeliness of thrombolytic therapy”, Statistics in Medicine, Vol. 24 No. 5, pp. 791-816. Batailler, P., Francois, P., Van Dang, M., Sellier, E., Vittoz, J.P., Seigneurin, A. and Labarere, J. (2014), “Trends in patients’ hospital quality perceptions”, International Journal of Health Care Quality Assurance, Vol. 27, No. 5. Bovier, P.A., Charvet, A., Cleopas, A., Vogt, N. and Perneger, T.V. (2004), “Self-reported management of pain in hospitalized patients: link between process and outcome”, American Journal of Medicine, Vol. 117 No. 8, pp. 569-574. Carpenter, I., Ram, M.B., Croft, G.P. and Williams, J.G. (2007), “Medical records and recordkeeping standards”, Clinical Medicine, Vol. 7 No. 4, pp. 328-331. Chisholm, C.D., Weaver, C.S., Whenmouth, L.F., Giles, B. and Brizendine, E.J. (2008), “A comparison of observed versus documented physician assessment and treatment of pain: the physician record does not reflect the reality”, Annals of Emergency Medicine, Vol. 52 No. 4, pp. 383-389.
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Corriol, C., Daucourt, V., Grenier, C. and Minvielle, E. (2008), “How to limit the burden of data collection for quality indicators based on medical records? The COMPAQH experience”, BMC Health Services Research, Vol. 8, p. 215. Couralet, M., Leleu, H., Capuano, F., Marcotte, L., Nitenberg, G., Sicotte, C. and Minvielle, E. (2013), “Method for developing national quality indicators based on manual data extraction from medical records”, BMJ Quality and Safety, Vol. 22 No. 2, pp. 155-162. Daucourt, V. and Michel, P. (2003), “Results of the first 100 accreditation procedures in France”, International Journal for Quality in Health Care, Vol. 15 No. 6, pp. 463-471. Dunlay, S.M., Alexander, K.P., Melloni, C., Kraschnewski, J.L., Liang, L., Gibler, W.B., Roe, M.T., Ohman, E.M. and Peterson, E.D. (2008), “Medical records and quality of care in acute coronary syndromes: results from CRUSADE”, Archives of Internal Medicine, Vol. 168 No. 15, pp. 1692-1698. Gabbay, J. and Layton, A.J. (1992), “Evaluation of audit of medical inpatient records in a district general hospital”, Quality in Health Care, Vol. 1 No. 1, pp. 43-47. Hanna, M.N., Gonzalez-Fernandez, M., Barrett, A.D., Williams, K.A. and Pronovost, P. (2012), “Does patient perception of pain control affect patient satisfaction across surgical units in a tertiary teaching hospital?”, American Journal of Medical Quality, Vol. 27 No. 5, pp. 411-416. Hansen, L.O., Strater, A., Smith, L., Lee, J., Press, R., Ward, N., Weigelt, J.A., Boling, P. and Williams, M.V. (2011), “Hospital discharge documentation and risk of rehospitalisation”, BMJ Quality and Safety, Vol. 20 No. 9, pp. 773-778. Huston, J.L. (2004), “The need for mandatory clinical recording standards”, Clinical Medicine, Vol. 4 No. 3, pp. 255-257. Jha, A.K., Orav, E.J., Zheng, J. and Epstein, A.M. (2008), “Patients’ perception of hospital care in the United States”, New England Journal of Medicine, Vol. 359 No. 18, pp. 1921-1931. Kazley, A.S., Diana, M.L., Ford, E.W. and Menachemi, N. (2012), “Is electronic health record use associated with patient satisfaction in hospitals?”, Health Care Management Review, Vol. 37 No. 1, pp. 23-30. Kelly, A.M. (2000), “Patient satisfaction with pain management does not correlate with initial or discharge VAS pain score, verbal pain rating at discharge, or change in VAS score in the emergency department”, Journal of Emergency Medicine, Vol. 19 No. 2, pp. 113-116. Kripalani, S., Lefevre, F., Phillips, C.O., Williams, M.V., Basaviah, P. and Baker, D.W. (2007), “Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care”, Journal of the American Medical Association, Vol. 297 No. 8, pp. 831-841. Labarere, J., Fourny, M., Vittoz, J.P., Marin-Pache, S. and Francois, P. (2004), “Refinement and validation of a French in-patient experience questionnaire”, International Journal of Health Care Quality Assurance, Vol. 17 No. 1, pp. 17-25. Labarere, J., Francois, P., Auquier, P., Robert, C. and Fourny, M. (2001), “Development of a French inpatient satisfaction questionnaire”, International Journal for Quality in Health Care, Vol. 13 No. 2, pp. 99-108. Leiter, M.P., Harvie, P. and Frizzell, C. (1998), “The correspondence of patient satisfaction and nurse burnout”, Social Science and Medicine, Vol. 47 No. 10, pp. 1611-1617. Luck, J., Peabody, J.W., Dresselhaus, T.R., Lee, M. and Glassman, P. (2000), “How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record”, American Journal of Medicine, Vol. 108 No. 8, pp. 642-649. Luxford, K. (2012), “What does the patient know about quality?”, International Journal for Quality in Health Care, Vol. 24 No. 5, pp. 439-440.
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Mann, R. and Williams, J. (2003), “Standards in medical record keeping”, Clinical Medicine, Vol. 3 No. 4, pp. 329-332. Martin, C.A. (1992), “Improving the quality of medical record documentation”, Journal for Healthcare Quality, Vol. 14 No. 3, pp. 16-23. Osborn, G.D., Pike, H., Smith, M., Winter, R. and Vaughan-Williams, E. (2005), “Quality of clinical case note entries: how good are we at achieving set standards?”, Annals of Royal College of Surgeons England, Vol. 87 No. 6, pp. 458-460. Royal College of Physicians (2008a), “A clinician’s guide to record standards-Part 1: why standardise the structure and content of medical records?”, available at: www.rcoa.ac.uk/ sites/default/files/FPM-clinicians-guide1.pdf (accessed June 10, 2013). Royal College of Physicians (2008b), “A clinician’s guide to record standards-Part 2: standards for the structure and content of medical records and communications when patients are admitted to hospital”, available at: www.rcoa.ac.uk/sites/default/files/FPM-cliniciansguide2.pdf (accessed June 10, 2013). Sack, C., Scherag, A., Lutkes, P., Gunther, W., Jockel, K.H. and Holtmann, G. (2011), “Is there an association between hospital accreditation and patient satisfaction with hospital care? A survey of 37,000 patients treated by 73 hospitals”, International Journal for Quality in Health Care, Vol. 23 No. 3, pp. 278-283. Siegler, E.L. (2010), “The evolving medical record”, Annals of Internal Medicine, Vol. 153 No. 10, pp. 671-677. Solomon, D.H., Schaffer, J.L., Katz, J.N., Horsky, J., Burdick, E., Nadler, E. and Bates, D.W. (2000), “Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care”, Medical Care, Vol. 38 No. 4, pp. 383-391. Stange, K.C., Zyzanski, S.J., Smith, T.F., Kelly, R., Langa, D.M., Flocke, S.A. and Jaen, C.R. (1998), “How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits”, Medical Care, Vol. 36 No. 6, pp. 851-867. Wood, D.L. (2001), “Documentation guidelines: evolution, future direction, and compliance”, American Journal of Medicine, Vol. 110 No. 4, pp. 332-334. Zegers, M., De Bruijne, M.C., Spreeuwenberg, P., Wagner, C., Groenewegen, P.P. and Van Der Wal, G. (2011), “Quality of patient record keeping: an indicator of the quality of care?”, BMJ Quality and Safety, Vol. 20 No. 4, pp. 314-318. Corresponding author Dr Jose´ Labare`re can be contacted at: [email protected]
(The Appendix follows overleaf.)
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Appendix 1 Perception of hospital care quality scores and items
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Table AI. Patients’ hospital care quality perceptions
I. Nurses’ interpersonal and technical skillsa 1. Nurses’ availability, n (%)b 2. Nurses’ courtesy, n (%)b 3. Prompt response to call button, n (%)b 4. Pain control, n (%)b 5. Nurses’ technical skills, n (%)b 6. Nurses’ interest in patient’s worries and needs, n (%)b 7. Waiting time following admission, n (%)b II. Informationa 8. Information about side effects of medications, n (%)b 9. Information about purpose of tests or treatments, n (%)b 10. Communication of tests results, n (%)b 11. Provision of information in an understandable way, n (%)b III. Continuity of carea 12. Information on recovery process, n (%)b 13. Instructions about medical follow-up, n (%)b 14. Efficiency of the discharge procedure, n (%)b 15. Provision of information to family members, n (%)b IV. Physicians’ interpersonal and technical skillsa 16. Frequency of physicians’ visits, n (%)b 17. Physicians introduced themselves, n (%)b 18. Physicians’ technical skills, n (%)b 19. Given explanation before being examined, n (%)b V. Living arrangementsa 20. Quietness, n (%)b 21. Comfort of room, n (%)b 22. Quality of food, n (%)b 23. Cleanliness, n (%)b 24. Staff knocked on the door, n (%)b 25. Respect of privacy, n (%)b VI. Conveniencea 26. Administrative admission process, n (%)b 27. Quality of care provided by x-ray staff, n (%)b 28. Finding one’s way within the hospital building, n (%)b 29. Test coordination and scheduling, n (%)b Overalla
N ¼ 191 81 168 181 142 150 180 173 169 75 141 162 137 155 83 119 149 168 134 75 153 140 182 163 78 155 160 155 175 161 175 78 170 144 134 157 77
(67-95) (89.8) (95.3) (81.6) (91.5) (95.7) (92.0) (88.9) (58-92) (81.5) (87.6) (76.1) (87.1) (67-92) (76.3) (87.6) (91.3) (80.2) (67-92) (83.6) (76.5) (97.2) (89.6) (67-89) (82.9) (87.0) (82.9) (93.6) (91.0) (92.6) (67-89) (92.4) (93.5) (75.3) (89.7) (68-87)
Notes: aData are median (25th-75th percentiles). Patient perception scores range between 0 and 100, with higher scores denoting better rating; bdata are patient numbers (percentages) very or fairly satisfied. Values were missing for the following items: nurses’ availability (n ¼ 4), nurses’ courtesy (n ¼ 1), prompt response to call button (n ¼ 17), pain control (n ¼ 27), nurse technical skills (n ¼ 3), nurse interest in patient’s worries and needs (n ¼ 3), waiting time following admission (n ¼ 1), information about medication side effects (n ¼ 18), information about test or treatment purpose (n ¼ 6), communicating tests results (n ¼ 11), information provision in an understandable way (n ¼ 13), information on recovery process (n ¼ 35), instructions about medical follow-up (n ¼ 21), discharge procedure efficiency (n ¼ 7), providing information to family members (n ¼ 24), frequency of physician visits (n ¼ 8), physicians introduced themselves (n ¼ 8), physician technical skills (n ¼ 4), given explanation before being examined (n ¼ 9), quietness (n ¼ 4), room comfort (n ¼ 7), food quality (n ¼ 4), cleanliness (n ¼ 4), staff knocked on the door (n ¼ 14), respect of privacy (n ¼ 2), administrative admission process (n ¼ 7), care quality provided by x-ray staff (n ¼ 37), finding one’s way within the hospital building (n ¼ 13) and test coordination and scheduling (n ¼ 16)
Composite score computed as the number of standards receiving a “yes” score divided by the number of applicable standards: 1. Presence of hospital admission entry (clerking): yes/no 2. Complete hospital admission entry (clerking): yes/noa 3. Complete medication orders: yes/nob 4. Presence of surgical or invasive procedure notes: yes/no/na 5. Presence of delivery notes: yes/no/na 6. Complete anesthetic record: yes/no/nac 7. Complete blood transfusion record: yes/no/na 8. Complete discharge medication order: yes/no/nad 9. Complete discharge summary: yes/noe 10. Medical record structured and organized: yes/no Range: 0-100, with higher scores denoting better compliance Documentation of pain assessment status consisting of at least one evaluation in a painless patient and two evaluations in a painful patient. Each evaluation should be performed using a pain assessment scale (visual analog scale or other) Documentation of body weight
Presence of a complete discharge summary in the medical record, dated within eight days following dischargee
Overall medical record-keeping score
Timely discharge summary completion
Age o18 years Discharge from an emergency department observation unit Length of stay o2 days Transfer to an intensive care unit, observation unit, palliative care unit, or obstetrics department within two days of admission Discharge from an emergency department observation unit Discharge by death
Discharge from an emergency department observation unit
Discharge from an emergency department observation unit
Exclusion criteria
Notes: na, not applicable. aComplete hospital admission entry included: (1) reason for admission and presenting complaints; (2) past medical history and relevant risk factors; (3) current medications; and (4) concluding notes from the clerking physician; bcomplete medication order included: (1) patient first and last name; (2) date; (3) physician signature; (4) physician last name; (5) drug name; (6) dosage; and (7) administration route. All medication orders made within the first 72 h following hospital admission were assessed for completeness. cComplete anesthetic record included: (1) preanesthesia evaluation documentation; (2) intraoperative notes; and (3) postoperative assessment. dComplete discharge medication order included: (1) patient first and last name; (2) date; (3) physician signature; (4) physician last name; (5) drug name; (6) dosage; (7) administration route; and (8) treatment duration. eComplete discharge summary included: (1) patient’s general practitioner name and address; (2) admission and discharge dates; (3) diagnosis and management; and (4) discharge medication regimen
Nutritional disorder screening documentation
Pain assessment documentation
Description
Standards
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Appendix 2
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Table AII. Medical record-keeping standards
Article information:
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To cite this document: Van Mô Dang Patrice François Pierre Batailler Arnaud Seigneurin Jean-Philippe Vittoz Elodie Sellier José Labarère , (2014),"Medical record-keeping and patient perception of hospital care quality", International Journal of Health Care Quality Assurance, Vol. 27 Iss 6 pp. 531 - 543 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-06-2013-0072 Downloaded on: 16 June 2015, At: 08:58 (PT) References: this document contains references to 34 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 511 times since 2014*
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Medical record-keeping and patient perception of hospital care quality Van Moˆ Dang Department of Medicine, Division of Geriatrics, Grenoble University Hospital, Grenoble, France, and
Patrice Franc¸ois, Pierre Batailler, Arnaud Seigneurin, Jean-Philippe Vittoz, Elodie Sellier and Jose´ Labare`re
Medical record-keeping
531 Received 2 February 2013 Revised 4 February 2014 Accepted 23 March 2014
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Quality of Care Unit, Grenoble University Hospital, Grenoble, France Abstract Purpose – Medical record represents the main information support used by healthcare providers. The purpose of this paper is to examine whether patient perception of hospital care quality related to compliance with medical-record keeping. Design/methodology/approach – The authors merged the original data collected as part of a nationwide audit of medical records with overall and subscale perception scores (range 0-100, with higher scores denoting better rating) computed for 191 respondents to a cross-sectional survey of patients discharged from a university hospital. Findings – The median overall patient perception score was 77 (25th-75th percentiles, 68-87) and differed according to the presence of discharge summary completed within eight days of discharge (81 v. 75, p ¼ 0.03 after adjusting for baseline patient and hospital stay characteristics). No independent associations were found between patient perception scores and the documentation of pain assessment and nutritional disorder screening. Yet, medical record-keeping quality was independently associated with higher patient perception scores for the nurses’ interpersonal and technical skills component. Research limitations/implications – First, this was a single-center study conducted in a large full-teaching hospital and the findings may not apply to other facilities. Second, the analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, the authors could not investigate whether electronic medical record contributed to better compliance with recording standards and eventually higher patient perception scores. Practical implications – Because of the potential consequences of poor recording for patient safety, further efforts are warranted to improve the accuracy and completeness of documentation in medical records. Originality/value – A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care. Keywords Patient satisfaction, Documentation, Hospitals, Medical records, Quality standards Paper type Research paper
Introduction Although medical records serve many functions, their primary purpose is to record information about patients and their care (Huston, 2004; Mann and Williams, 2003). Medical records provide clinical staff caring for patients with information needed to deliver optimal care in present or future hospital episodes (Carpenter et al., 2007). Medical-record structure and content have attracted interest for decades (Siegler, 2010). Yet medical record-keeping quality is highly variable (Daucourt and Michel, 2003; Mann and Williams, 2003; Osborn et al., 2005). Medical record and communication standards have been developed in North America and Europe (Royal College of
International Journal of Health Care Quality Assurance Vol. 27 No. 6, 2014 pp. 531-543 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-06-2013-0072
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Physicians, 2008a, b; Wood, 2001). Adopting such standards has benefits including completeness and accuracy (Mann and Williams, 2003; Martin, 1992), better communication between clinical care providers (Mann and Williams, 2003) and decreased adverse events (Zegers et al., 2011). Few studies report a link between sub-optimal medical records, care processes and clinical outcomes for patients with specific conditions (Dunlay et al., 2008) and none investigate the potential association between medical-record keeping and patients’ hospital care perceptions. This study aimed to determine whether patient perceptions are related to medical-record quality. Specifically, we hypothesized that higher compliance with medical record-keeping standards were observed for patients reporting higher perception scores. If such an association is found then patient satisfaction with care might be an incentive for improving medical records. Methods Study design We merged original data from a nationwide medical-record audit with responses to a cross-sectional university hospital patient survey. Individual-level compliance with medical-record standards were linked to respondent perception scores via hospital identifiers. Because the two studies were designed and conducted independently, fewer patients appeared in both samples. To increase our sample size, we elected to audit additional medical records, which were randomly selected among the cross-sectional survey respondents. Study site Grenoble University Hospital is a full-teaching hospital with 1,347 acute-care beds serving a predominantly urban population (450,000). It also serves as the regional referral centre for the French Northern Alps. Hospital data show 58,412 acute-care stays, with a 6.7 days mean stay in 2010. Patient hospital care quality perception In total, 1,500 patients discharged consecutively from acute-care departments were selected in April 2010 (Batailler et al., 2014). Medical, surgical or obstetrics and gynecology inpatients staying more than one day were eligible if they were discharged alive to home or to a nursing home. Patients transferred to other acute care hospitals and those discharged to post-acute care facilities were not eligible. There was no diagnostic limitation to patient selection. The patients’ care quality perceptions were collected using a standardized survey instrument (Labarere et al., 2001), which included 29 items covering six key hospital care quality components: physician and nurse interpersonal and technical skills, information, continuity, convenience and living arrangements (Appendix 1). Each item was rated on a four-point Likert scale ranging from strongly disagree (1) to strongly agree (4). The survey instrument also included an overall satisfaction item and two items dealing with patient’s intent to recommend the hospital and to return to the hospital for care. The questionnaire was mailed to patients within two to four weeks of discharge along with a pre-paid envelope, a letter guaranteeing patient confidentiality and encouraging participation. A follow-up letter was sent to non-respondents two weeks later. For each patient, we computed six subscale scores, each corresponding to a hospital care quality component and an overall score based on his/her 29 item ratings. Each subscale score was computed as the mean of the individual items constituting the corresponding
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component. Subscale and overall scores ranged between 0 and 100; higher scores denoting better ratings. Subscale scores were coded as missing if more than half the corresponding items had omitted values. Questionnaires with more than six missing values (i.e. an overall proportion higher than 20 percent) were excluded from the analysis; the same strategy used in the original survey instrument’s development and validation (Labarere et al., 2004). Medical-record audit The French agency for healthcare quality (Haute autorite´ de sante´) requires hospital staff to audit medical record and discharge summary structure and content annually (Couralet et al., 2013). In 2010, 354 patients with stays longer than one day were randomly selected among the computerized discharge summaries recorded in our hospital administrative database. In total, 80 hospital stays were sampled to comply with the national audit requirements and 274 additional hospital stays were appraised for local convenience. We examined electronic and paper medical records and collected data using a centralized password-secured web site. The audit tool and help notes had been developed, pre-tested and assessed for inter-rater reliability during a pilot study (Corriol et al., 2008). The tool comprised 75 items and assessed overall medical-record keeping, pain assessment, nutritional disorder screening and discharge summary timeliness and completeness (Appendix 2). The overall medical-record score comprised ten items while the three other standards were binary. Because each standard yielded specific exclusion criteria, audited medical-record numbers varied across standards. Statistical analysis Categorical variables were reported as numbers and percentages, and continuous variables as median, 25th and 75th percentiles. In univariable analysis, differences in overall medical record-keeping score according to patient and hospital stay characteristics were compared using the non-parametric Kruskal-Wallis test. Pain assessment, nutritional disorder screening and timely discharge summary, according to patient and hospital stay characteristics, were analyzed using the w2 or Fisher exact test. We performed multivariable quantile regression analysis (Austin et al., 2005) to examine the independent associations between median patient perception scores and compliance with standards for overall medical-record keeping, pain assessment documentation, nutritional disorder screening documentation and discharge summary timeliness and completeness, respectively. To account for potential confounding by patient and hospital stay characteristics, the models were adjusted for age, gender, surgical procedure and length of stay (LoS). Patients enrolled in the two original studies determined the sample size and no a priori sample size calculation could be performed for this analysis. Two-tailed p-values o0.05 were considered statistically significant. All analyses were performed using Stata version 11.0 (Stata Corporation, College Station, TX, USA). This survey received the French Data Protection Agency’s (commission nationale de l’informatique et des liberte´s, Paris, France) approval. Results Overall, 870 of the 1,500 surveyed patients returned a questionnaire, yielding a 58 percent participation rate. Data collected from the medical record-keeping audit were available for 204 respondents. After excluding nine medical records and four survey questionnaires owing to exclusion criteria, the final sample was 191 patients.
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The median age for all patients was 58 years, 95 (49.7 percent) were female and 28 (14.7 percent) underwent a surgical procedure (Table I). The medical records included electronic and paper documentation for 154 patients (80.6 percent), and paper documents only for 37 patients (19.4 percent). The median overall medical-record quality score was 80/100, with standards compliance ranging from 46.7 percent for discharge medication order to 100 percent for delivery notes (Table II). Pain assessment and nutritional disorder screening documentation prevalence was 55.0 and 74.1 percent, respectively. A discharge summary was found in 117 (61.3 percent) medical records and was completed within eight days following discharge in 72 records (37.7 percent). Compliance with recording standards varied according to age and gender (overall medical-record quality score), surgical procedure (timely discharge summary completion, pain assessment and nutritional disorder screening documentation) and LoS (overall medical record-keeping quality score, timely discharge summary completion and pain assessment documentation) (Table III).
Characteristics
Table I. Patient and hospital characteristics
Age, ya Female gender, n (%) Education level lower than high school, n (%)b Admission to an emergency department observation unit, n (%) Admission to the maternity ward, n (%) Transfer to an intensive care unit within two days of admission, n (%) Surgical procedure, n (%) Discharge to another hospital, n (%) Length of stay, da
58 95 43 71 8 10 28 2 5
(42-73) (49.7) (22.5) (37.2) (4.2) (5.2) (14.7) (1.0) (4-9)
Notes: aData are given as median (25th-75th percentiles). bValues were missing for education level (n ¼ 12)
Standards
Table II. Compliance with medical record-keeping standards
N ¼ 191
Overall medical record-keeping score, median (25th-75th percentiles)a 1. Presence of hospital admission entry (clerking), n (%) 2. Complete hospital admission entry (clerking), n (%) 3. Complete medication orders, n (%) 4. Presence of surgical or invasive procedure notes, n (%) 5. Presence of delivery notes, n (%) 6. Complete anesthetic record, n (%) 7. Complete blood transfusion record, n (%) 8. Complete discharge medication order, n (%) 9. Complete discharge summary, n (%) 10. Medical record structured and organized, n (%) Pain assessment documentation, n (%) Nutritional disorder screening documentation, n (%) Timely discharge summary completion, n (%)
N ¼ 191 80 178 149 138/190 38/40 6/6 31/41 11/12 79/169 117 173 105 66/89 72
(60-88) (93.2) (78.0) (72.6) (95.0) (100.0) (75.6) (91.7) (46.7) (61.3) (90.6) (55.0) (74.1) (37.7)
Note: aThe medical record-keeping score was computed based on compliance with ten standards and ranged between 0 and 100, with higher scores denoting better compliance (see Methods)
67 (57-88) 67 (50-83) 83 (67-87) 86 (80-100)
80 (60-100) 83 (75-88) o0.001
0.25
19/47 19/55 28/44 39/45
(40.4) (34.5) (63.6) (86.7)
81/163 (49.7) 24/28 (85.7)
68/135 (50.4)
75 (60-88)
48/95 (50.5) 57/96 (59.4)
24/53 (45.2) 31/60 (51.7) 50/78 (64.1)
28/44 (63.6)
0.17
o0.001
0.04
Pain assessment documentation, n (%)
83 (67-100)
67 (50-83) 83 (67-100)
67 (60-88) 73 (50-86) 83 (67-100)
p
Note: aValues are given as median (25th-75th percentiles)
Age, y o45 45-64 X65 Gender Female Male Education level Lower than high school High school or higher Surgical procedure No Yes Length of stay, d p3 4-5 6-9 49
Characteristics
Overall medical record-keeping scorea
o0.001
o0.001
0.12
0.22
0.09
p
9/11 20/33 20/26 17/19
(81.8) (60.6) (76.9) (89.5)
47/69 (68.1) 19/20 (95.0)
47/61 (77.0)
16/25 (64.0)
30/44 (68.2) 36/45 (80.0)
16/19 (84.2) 23/34 (67.6) 27/36 (75.0)
Nutritional disorder screening documentation, n (%)
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0.13
0.02
0.21
0.20
0.45
p
13/47 15/55 23/44 21/45
(27.7) (27.3) (52.3) (46.7)
56/163 (34.4) 16/28 (57.1)
49/135 (36.3)
21/44 (47.7)
33/95 (34.7) 39/96 (40.6)
17/53 (32.1) 23/60 (38.3) 32/78 (41.0)
Timely discharge summary completion, n (%)
0.02
0.02
0.18
0.40
0.58
p
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Table III. Medical record-keeping according to patient baseline characteristics
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The median overall patient perception score was 77 (Table IV), with median subscale scores ranging from 75 for the information and physician interpersonal and technical skills components to 83 for the care continuity component (Table V). In multivariable analysis adjusting for patient and hospital stay characteristics, timely discharge summary was the only medical record-keeping standard associated with higher overall patient perception score (Table IV). No subscale patient perception score differed according to medical record-keeping standards, excepting nurses’ interpersonal and technical skills score, which was related to overall medical record-keeping score (Table V). Although pain assessment documentation was associated with a higher patient-percentage very or fairly satisfied with pain control (96.8 (92/95) v. 84.1 percent (58/69), p ¼ 0.004), this difference did not remain significant after adjusting for covariates. Overall, 172 patients (90.0 percent) were very or fairly satisfied with hospital care. Higher overall medical record-keeping scores were observed in very or fairly satisfied patients (median, 81 (60-88) v. 67 (60-67), p ¼ 0.04). Regarding behavioral intentions, 161 patients (84.3 percent) reported that they would likely or very likely recommend the hospital and return to the hospital for care, with no differences according to compliance with recording standards. Discussion We found limited evidence supporting a potential relationship between patient hospital care perception and compliance with medical record-keeping standards. Overall, perceptions related only to the discharge summary timeliness and completeness. No independent associations were observed between patient perception components and compliance with recording standards other than a link between overall medical-record keeping and nurses’ interpersonal and technical skills. Consistent with prior research, we identified low overall medical record-keeping quality (Gabbay and Layton, 1992; Mann and Williams, 2003), pain assessment and nutritional disorder screening (Gabbay and Layton, 1992) and discharge summary completion (Hansen et al., 2011). Because the medical record represents the main Standards
Table IV. Overall patient hospital care quality perception score according to medical-record keeping
All patients Overall medical record-keeping score p80 480 Pain assessment documentation No Yes Nutritional disorder screening documentation No Yes Timely discharge summary completion No Yes
Overall perception of hospital care quality scorea pb 77 (68-87)
– 0.86
76 (64-84) 79 (71-90) 0.73 77 (65-83) 78 (70-91) 0.80 80 (73-86) 79 (68-91) 0.03 75 (64-84) 81 (73-90)
Notes: aData are given as median (25th-75th percentiles). Patient perception scores range between 0 and 100, with higher scores denoting better rating. bp-values were adjusted for age, gender, surgical procedure, and length of stay
75 (58-92) 83 (67-92)
92 (67-92) 75 (58-92)
71 (58-92) 75 (67-92)
75 (58-92) 75 (67-92)
78 (62-93) 86 (76-95) Physicians’ interpersonal and technical skills 75 (67-92)
86 (71-95) 86 (67-95)
77 (67-93) 86 (71-95)
78 (67-93) 86 (74-95)
Nurses’ interpersonal and technical skills 81 (67-95)
0.54
0.54
0.50
pb – 0.78
0.23
0.95
0.23
pb – 0.04
78 (61-89) 83 (67-94)
78 (67-94) 83 (72-94)
78 (61-89) 83 (67-92)
78 (61-89) 83 (67-94)
67 (50-92) 75 (67-92) Living arrangements 78 (67-89)
83 (67-92) 75 (67-92)
67 (55-92) 75 (67-92)
75 (50-92) 75 (67-92)
Information 75 (58-92)
0.05
0.06
0.37
pb – 0.21
0.36
0.21
0.38
pb – 0.70
Perception of hospital care quality scorea
67 (58-83) 75 (67-89)
75 (67-92) 75 (58-89)
75 (67-83) 75 (62-89)
67 (58-83) 75 (67-89)
Convenience 78 (67-89)
75 (58-92) 83 (67-92)
76 (67-92) 83 (67-92)
75 (58-92) 83 (67-92)
75 (58-92) 83 (67-92)
Continuity of care 83 (67-92)
0.36
0.37
0.18
pb – 0.08
0.16
0.80
0.14
pb – 0.26
Notes: aData are given as median (25th-75th percentiles). Patient perception scores ranged between 0 and 100, with higher scores denoting better rating. b p-values were adjusted for age, gender, surgical procedure and length of stay
All patients Overall medical record-keeping score p80 480 Pain assessment documentation No Yes Nutritional disorder screening documentation No Yes Timely discharge summary completion No Yes
All patients Overall medical record-keeping score p80 480 Pain assessment documentation No Yes Nutritional disorder screening documentation No Yes Timely discharge summary completion No Yes
Standards
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Table V. Subscale patient hospital care quality perception scores according to medical–record keeping
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information for healthcare providers, these findings imply potentially harmful consequences for patient safety. Accordingly, higher adverse event rates are associated with poor information recorded in medical charts (Zegers et al., 2011). Although speculative, a potential explanation for the association between medical-record keeping and nurses’ skills scores is that the nurses who document hospital records more thoroughly may also have better interpersonal skills, leading to higher patient perception. Indeed, patient information recorded in hospital chart likely reflects the interaction between healthcare providers and the patient (Solomon et al., 2000). Yet, this hypothesis is partly contradicted by our failure to show a similar association involving physician interpersonal and technical skills. It is also possible that medical-record keeping and nurses’ interpersonal and technical skills have a common origin in safety culture and work environment. On one hand, medical record-keeping quality is part of the hospital work environment besides other aspects like physician-nurse relations, nurse participation in decision making and organizational priorities on care quality. On the other hand, consistent associations between patient hospital care ratings, nurse work environment and safety culture have been reported across western countries (Aiken et al., 2012). In this context, that patients with higher overall medical record-keeping scores were more likely to be satisfied with their hospital stay was expected, since nursing care perceptions strongly influences patient satisfaction (Leiter et al., 1998). Interestingly, an independent association was found between overall patient hospital-care perception and discharge summaries completed within eight days post discharge. This finding accords with studies reporting that deficits in information transfer between hospital-based and primary care physicians at discharge have the potential to negatively affect continuity and safety (Kripalani et al., 2007). The weak association between patient perception and pain assessment documentation was unexpected. Presumably, patients with documented pain assessment would report higher perception scores for nurse interpersonal and technical skills, since this subscale comprised an individual item relating to pain control. However, no independent association was observed between pain assessment documentation and patient-reported pain control in our study. This observation may mirror a gap between objectively documented pain assessment and patient satisfaction with pain control. Although its determinants are not fully understood, patient satisfaction stems from the discrepancy between patient expectations and perceived experience, which may differ from actual experience. Patient-reported pain management procedures is associated with pain relief (Bovier et al., 2004) but complex relationships exist between patient satisfaction with pain management and objective pain level measures, delayed analgesia and pain relief (Hanna et al., 2012; Kelly, 2000). There are several potential explanations for the modest relationship between compliance with medical record-keeping standards and patient hospital care quality perceptions. First, our data represent medical record documentation rather than observing care directly. Substantial disagreement has been previously demonstrated between medical record and direct observation, with the potential for chart abstraction underestimating care quality (Chisholm et al., 2008; Luck et al., 2000; Stange et al., 1998). Conversely, adequate care may be documented in medical records despite providing inadequate care, in an attempt to comply with regulatory standards (Hansen et al., 2011). Second, only modest associations exist between technical care and patient experience (Jha et al., 2008; Sack et al., 2011). Indeed, patients may rely on
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peripheral elements such as comfort, emotional support and friendliness because they do not feel competent to evaluate technical skills (Luxford, 2012). Third, we cannot say that our survey instrument was valid (Batailler et al., 2014), although this was unlikely. We used a self-administered French-language questionnaire developed according to psychometric theory that demonstrated satisfactory validity and reliability (Labarere et al., 2001). Our study has limitations; first this was a single-centre study conducted in a large teaching hospital and the findings may not apply to other facilities. Second, the sample size was determined by patients enrolled in the satisfaction survey and the medical-record audit. Hence, our analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, a recent study reported a positive association between hospital electronic health records and patient satisfaction (Kazley et al., 2012). Because the medical records were hybrid, including electronic and paper documents for most patients enrolled in our study (80.6 percent), we could not investigate whether electronic medical records contribute to better compliance with recording standards and eventually higher patient scores. However, computerized documentation also has specific drawbacks, including unintended copying and pasting. Conclusions We found only weak associations between compliance with medical-record keeping and patient care quality perceptions. It remains unclear whether these findings result from a failure to provide or to document adequate care. Because poor recording has consequences for patient safety, further efforts are warranted to improve medicalrecord accuracy and completeness. References Aiken, L.H., Sermeus, W., Van Den Heede, K., Sloane, D.M., Busse, R., Mckee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L. and Kutney-Lee, A. (2012), “Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States”, British Medical Journal, Vol. 344, p. e1717. Austin, P.C., Tu, J.V., Daly, P.A. and Alter, D.A. (2005), “The use of quantile regression in health care research: a case study examining gender differences in the timeliness of thrombolytic therapy”, Statistics in Medicine, Vol. 24 No. 5, pp. 791-816. Batailler, P., Francois, P., Van Dang, M., Sellier, E., Vittoz, J.P., Seigneurin, A. and Labarere, J. (2014), “Trends in patients’ hospital quality perceptions”, International Journal of Health Care Quality Assurance, Vol. 27, No. 5. Bovier, P.A., Charvet, A., Cleopas, A., Vogt, N. and Perneger, T.V. (2004), “Self-reported management of pain in hospitalized patients: link between process and outcome”, American Journal of Medicine, Vol. 117 No. 8, pp. 569-574. Carpenter, I., Ram, M.B., Croft, G.P. and Williams, J.G. (2007), “Medical records and recordkeeping standards”, Clinical Medicine, Vol. 7 No. 4, pp. 328-331. Chisholm, C.D., Weaver, C.S., Whenmouth, L.F., Giles, B. and Brizendine, E.J. (2008), “A comparison of observed versus documented physician assessment and treatment of pain: the physician record does not reflect the reality”, Annals of Emergency Medicine, Vol. 52 No. 4, pp. 383-389.
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Corriol, C., Daucourt, V., Grenier, C. and Minvielle, E. (2008), “How to limit the burden of data collection for quality indicators based on medical records? The COMPAQH experience”, BMC Health Services Research, Vol. 8, p. 215. Couralet, M., Leleu, H., Capuano, F., Marcotte, L., Nitenberg, G., Sicotte, C. and Minvielle, E. (2013), “Method for developing national quality indicators based on manual data extraction from medical records”, BMJ Quality and Safety, Vol. 22 No. 2, pp. 155-162. Daucourt, V. and Michel, P. (2003), “Results of the first 100 accreditation procedures in France”, International Journal for Quality in Health Care, Vol. 15 No. 6, pp. 463-471. Dunlay, S.M., Alexander, K.P., Melloni, C., Kraschnewski, J.L., Liang, L., Gibler, W.B., Roe, M.T., Ohman, E.M. and Peterson, E.D. (2008), “Medical records and quality of care in acute coronary syndromes: results from CRUSADE”, Archives of Internal Medicine, Vol. 168 No. 15, pp. 1692-1698. Gabbay, J. and Layton, A.J. (1992), “Evaluation of audit of medical inpatient records in a district general hospital”, Quality in Health Care, Vol. 1 No. 1, pp. 43-47. Hanna, M.N., Gonzalez-Fernandez, M., Barrett, A.D., Williams, K.A. and Pronovost, P. (2012), “Does patient perception of pain control affect patient satisfaction across surgical units in a tertiary teaching hospital?”, American Journal of Medical Quality, Vol. 27 No. 5, pp. 411-416. Hansen, L.O., Strater, A., Smith, L., Lee, J., Press, R., Ward, N., Weigelt, J.A., Boling, P. and Williams, M.V. (2011), “Hospital discharge documentation and risk of rehospitalisation”, BMJ Quality and Safety, Vol. 20 No. 9, pp. 773-778. Huston, J.L. (2004), “The need for mandatory clinical recording standards”, Clinical Medicine, Vol. 4 No. 3, pp. 255-257. Jha, A.K., Orav, E.J., Zheng, J. and Epstein, A.M. (2008), “Patients’ perception of hospital care in the United States”, New England Journal of Medicine, Vol. 359 No. 18, pp. 1921-1931. Kazley, A.S., Diana, M.L., Ford, E.W. and Menachemi, N. (2012), “Is electronic health record use associated with patient satisfaction in hospitals?”, Health Care Management Review, Vol. 37 No. 1, pp. 23-30. Kelly, A.M. (2000), “Patient satisfaction with pain management does not correlate with initial or discharge VAS pain score, verbal pain rating at discharge, or change in VAS score in the emergency department”, Journal of Emergency Medicine, Vol. 19 No. 2, pp. 113-116. Kripalani, S., Lefevre, F., Phillips, C.O., Williams, M.V., Basaviah, P. and Baker, D.W. (2007), “Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care”, Journal of the American Medical Association, Vol. 297 No. 8, pp. 831-841. Labarere, J., Fourny, M., Vittoz, J.P., Marin-Pache, S. and Francois, P. (2004), “Refinement and validation of a French in-patient experience questionnaire”, International Journal of Health Care Quality Assurance, Vol. 17 No. 1, pp. 17-25. Labarere, J., Francois, P., Auquier, P., Robert, C. and Fourny, M. (2001), “Development of a French inpatient satisfaction questionnaire”, International Journal for Quality in Health Care, Vol. 13 No. 2, pp. 99-108. Leiter, M.P., Harvie, P. and Frizzell, C. (1998), “The correspondence of patient satisfaction and nurse burnout”, Social Science and Medicine, Vol. 47 No. 10, pp. 1611-1617. Luck, J., Peabody, J.W., Dresselhaus, T.R., Lee, M. and Glassman, P. (2000), “How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record”, American Journal of Medicine, Vol. 108 No. 8, pp. 642-649. Luxford, K. (2012), “What does the patient know about quality?”, International Journal for Quality in Health Care, Vol. 24 No. 5, pp. 439-440.
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Mann, R. and Williams, J. (2003), “Standards in medical record keeping”, Clinical Medicine, Vol. 3 No. 4, pp. 329-332. Martin, C.A. (1992), “Improving the quality of medical record documentation”, Journal for Healthcare Quality, Vol. 14 No. 3, pp. 16-23. Osborn, G.D., Pike, H., Smith, M., Winter, R. and Vaughan-Williams, E. (2005), “Quality of clinical case note entries: how good are we at achieving set standards?”, Annals of Royal College of Surgeons England, Vol. 87 No. 6, pp. 458-460. Royal College of Physicians (2008a), “A clinician’s guide to record standards-Part 1: why standardise the structure and content of medical records?”, available at: www.rcoa.ac.uk/ sites/default/files/FPM-clinicians-guide1.pdf (accessed June 10, 2013). Royal College of Physicians (2008b), “A clinician’s guide to record standards-Part 2: standards for the structure and content of medical records and communications when patients are admitted to hospital”, available at: www.rcoa.ac.uk/sites/default/files/FPM-cliniciansguide2.pdf (accessed June 10, 2013). Sack, C., Scherag, A., Lutkes, P., Gunther, W., Jockel, K.H. and Holtmann, G. (2011), “Is there an association between hospital accreditation and patient satisfaction with hospital care? A survey of 37,000 patients treated by 73 hospitals”, International Journal for Quality in Health Care, Vol. 23 No. 3, pp. 278-283. Siegler, E.L. (2010), “The evolving medical record”, Annals of Internal Medicine, Vol. 153 No. 10, pp. 671-677. Solomon, D.H., Schaffer, J.L., Katz, J.N., Horsky, J., Burdick, E., Nadler, E. and Bates, D.W. (2000), “Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care”, Medical Care, Vol. 38 No. 4, pp. 383-391. Stange, K.C., Zyzanski, S.J., Smith, T.F., Kelly, R., Langa, D.M., Flocke, S.A. and Jaen, C.R. (1998), “How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits”, Medical Care, Vol. 36 No. 6, pp. 851-867. Wood, D.L. (2001), “Documentation guidelines: evolution, future direction, and compliance”, American Journal of Medicine, Vol. 110 No. 4, pp. 332-334. Zegers, M., De Bruijne, M.C., Spreeuwenberg, P., Wagner, C., Groenewegen, P.P. and Van Der Wal, G. (2011), “Quality of patient record keeping: an indicator of the quality of care?”, BMJ Quality and Safety, Vol. 20 No. 4, pp. 314-318. Corresponding author Dr Jose´ Labare`re can be contacted at: [email protected]
(The Appendix follows overleaf.)
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Appendix 1 Perception of hospital care quality scores and items
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Table AI. Patients’ hospital care quality perceptions
I. Nurses’ interpersonal and technical skillsa 1. Nurses’ availability, n (%)b 2. Nurses’ courtesy, n (%)b 3. Prompt response to call button, n (%)b 4. Pain control, n (%)b 5. Nurses’ technical skills, n (%)b 6. Nurses’ interest in patient’s worries and needs, n (%)b 7. Waiting time following admission, n (%)b II. Informationa 8. Information about side effects of medications, n (%)b 9. Information about purpose of tests or treatments, n (%)b 10. Communication of tests results, n (%)b 11. Provision of information in an understandable way, n (%)b III. Continuity of carea 12. Information on recovery process, n (%)b 13. Instructions about medical follow-up, n (%)b 14. Efficiency of the discharge procedure, n (%)b 15. Provision of information to family members, n (%)b IV. Physicians’ interpersonal and technical skillsa 16. Frequency of physicians’ visits, n (%)b 17. Physicians introduced themselves, n (%)b 18. Physicians’ technical skills, n (%)b 19. Given explanation before being examined, n (%)b V. Living arrangementsa 20. Quietness, n (%)b 21. Comfort of room, n (%)b 22. Quality of food, n (%)b 23. Cleanliness, n (%)b 24. Staff knocked on the door, n (%)b 25. Respect of privacy, n (%)b VI. Conveniencea 26. Administrative admission process, n (%)b 27. Quality of care provided by x-ray staff, n (%)b 28. Finding one’s way within the hospital building, n (%)b 29. Test coordination and scheduling, n (%)b Overalla
N ¼ 191 81 168 181 142 150 180 173 169 75 141 162 137 155 83 119 149 168 134 75 153 140 182 163 78 155 160 155 175 161 175 78 170 144 134 157 77
(67-95) (89.8) (95.3) (81.6) (91.5) (95.7) (92.0) (88.9) (58-92) (81.5) (87.6) (76.1) (87.1) (67-92) (76.3) (87.6) (91.3) (80.2) (67-92) (83.6) (76.5) (97.2) (89.6) (67-89) (82.9) (87.0) (82.9) (93.6) (91.0) (92.6) (67-89) (92.4) (93.5) (75.3) (89.7) (68-87)
Notes: aData are median (25th-75th percentiles). Patient perception scores range between 0 and 100, with higher scores denoting better rating; bdata are patient numbers (percentages) very or fairly satisfied. Values were missing for the following items: nurses’ availability (n ¼ 4), nurses’ courtesy (n ¼ 1), prompt response to call button (n ¼ 17), pain control (n ¼ 27), nurse technical skills (n ¼ 3), nurse interest in patient’s worries and needs (n ¼ 3), waiting time following admission (n ¼ 1), information about medication side effects (n ¼ 18), information about test or treatment purpose (n ¼ 6), communicating tests results (n ¼ 11), information provision in an understandable way (n ¼ 13), information on recovery process (n ¼ 35), instructions about medical follow-up (n ¼ 21), discharge procedure efficiency (n ¼ 7), providing information to family members (n ¼ 24), frequency of physician visits (n ¼ 8), physicians introduced themselves (n ¼ 8), physician technical skills (n ¼ 4), given explanation before being examined (n ¼ 9), quietness (n ¼ 4), room comfort (n ¼ 7), food quality (n ¼ 4), cleanliness (n ¼ 4), staff knocked on the door (n ¼ 14), respect of privacy (n ¼ 2), administrative admission process (n ¼ 7), care quality provided by x-ray staff (n ¼ 37), finding one’s way within the hospital building (n ¼ 13) and test coordination and scheduling (n ¼ 16)
Composite score computed as the number of standards receiving a “yes” score divided by the number of applicable standards: 1. Presence of hospital admission entry (clerking): yes/no 2. Complete hospital admission entry (clerking): yes/noa 3. Complete medication orders: yes/nob 4. Presence of surgical or invasive procedure notes: yes/no/na 5. Presence of delivery notes: yes/no/na 6. Complete anesthetic record: yes/no/nac 7. Complete blood transfusion record: yes/no/na 8. Complete discharge medication order: yes/no/nad 9. Complete discharge summary: yes/noe 10. Medical record structured and organized: yes/no Range: 0-100, with higher scores denoting better compliance Documentation of pain assessment status consisting of at least one evaluation in a painless patient and two evaluations in a painful patient. Each evaluation should be performed using a pain assessment scale (visual analog scale or other) Documentation of body weight
Presence of a complete discharge summary in the medical record, dated within eight days following dischargee
Overall medical record-keeping score
Timely discharge summary completion
Age o18 years Discharge from an emergency department observation unit Length of stay o2 days Transfer to an intensive care unit, observation unit, palliative care unit, or obstetrics department within two days of admission Discharge from an emergency department observation unit Discharge by death
Discharge from an emergency department observation unit
Discharge from an emergency department observation unit
Exclusion criteria
Notes: na, not applicable. aComplete hospital admission entry included: (1) reason for admission and presenting complaints; (2) past medical history and relevant risk factors; (3) current medications; and (4) concluding notes from the clerking physician; bcomplete medication order included: (1) patient first and last name; (2) date; (3) physician signature; (4) physician last name; (5) drug name; (6) dosage; and (7) administration route. All medication orders made within the first 72 h following hospital admission were assessed for completeness. cComplete anesthetic record included: (1) preanesthesia evaluation documentation; (2) intraoperative notes; and (3) postoperative assessment. dComplete discharge medication order included: (1) patient first and last name; (2) date; (3) physician signature; (4) physician last name; (5) drug name; (6) dosage; (7) administration route; and (8) treatment duration. eComplete discharge summary included: (1) patient’s general practitioner name and address; (2) admission and discharge dates; (3) diagnosis and management; and (4) discharge medication regimen
Nutritional disorder screening documentation
Pain assessment documentation
Description
Standards
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Appendix 2
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Table AII. Medical record-keeping standards
