Use of an outpatient medical record audit to achieve educational objectives
Changes in residents’ performances over six years
Cite this article as: Kern, D.E., Harris, W.L., Boekeloo, B.O. et al. J Gen Intern Med (1990) 5: 218. doi:10.1007/BF02600538 Abstract
To evaluate the effectiveness of a process whereby a faculty-resident committee annually audits outpatient record keeping and preventive care practices and provides feedback to resident physicians.
Pre- and postfeedback audits with interventions and observations repeated over six consecutive academic years.
The adult primary care practice of housestaff in a university-affiliated hospital.
All 139 physicians in an internal medicine residency program from 1981–82 through 1986–87, of whom 37 were present for three consecutive years.
Each year, residents were given individualized, detailed, typewritten feedback based on audits of their outpatient records.
Measurements and main results:
Each resident physician had a minimum of four (mean 5.2) outpatient records per year audited against standards for record-keeping practices and the provision of preventive care. Overall performance scores for each resident audit improved from a mean of 39.7±12.3 (SD) in 1981–82 to a mean of 58.5±14.1 (SD) in 1986–87 (possible range 0 to 100, observed range 9.4 to 86.6). The overall performance scores of individual residents, who received two cycles of feedback, improved an average of 11.5 (95% confidence limits 7.6, 15.3), from a mean of 48.4±11.4 (SD) during their first year of residency to 59.8±13.9 (SD) during their third year. General (primary care) and traditional-track residents improved at similar rates, although mean performance scores were consistently higher for general than for traditional-track residents. Analysis of variance revealed that all changes and differences were statistically significant.
An ongoing chart audit and feedback system can be associated with improvements both in the performance of individual residents and in the long-term performance of a residency program. Key words medical audit feedback primary health care internship and residency medical records
Supported in part by a residency training grant from the Bureau of Health Professions, Health Resources and Services Administration.
Frame PC, Kowulich BA, Llewellyn AM. Improving physician compliance with a health maintenance protocol. J Fam Pract. 1984;19:341–4.
Lau RR, Williams HS, Williams LC, Ware JE, Brook RH. Psychosocial problems in chronically ill children: physician concern, patient satisfaction, and the validity of medical records. J Comm Health. 1982;7:250–61.
Moran MT, Wiser TH, Nada J, Gross H. Measuring medical residents’ chart documentation practices. J Med Educ. 1988;63:860–5.
Zuckerman AE, Starfield B, Hochreiter C, Kovasznay B. Validating the content of pediatric medical records by means of tape-recording doctor-patient encounters. Pediatrics. 1975;56:407–11.
Brook RH, Fink A, Kosecoff J, et al. Educating physicians and treating patients in the ambulatory setting: where are we going and how will we know when we arrive? Ann Intern Med. 1987;107:392–8.
Cheney C, Ramsdell JW. Effect of medical record checklists on implementation of periodic health measures. Am J Med. 1987;83:129–36.
Davidson RA, Fletcher SW, Retchins DVHS. A nurse-initiated reminder system for the periodic health examination. Arch Intern Med. 1984;144:2167–70.
Dietrich AJ, Goldberg H. Preventive content of adult primary care: do generalists and subspecialists differ? Am J Public Health. 1984;74:223–7.
Fleming DM, Lawrence MSTA. Impact of audit on preventive measures. Br Med J. 1983;287:1852–4.
Korn JE, Schlossberg LA, Rich EC. Improved preventive care following an intervention during an ambulatory care rotation: carryover to a second setting. J Gen Intern Med. 1988;3:156–60.
Lurie N, Manning WG, Peterson C, Goldberg GA, Phelps CA, Lillard L. Preventive care: do we practice what we preach? Am J Public Health. 1987;77:801–4.
McDonald CJ, Hui SL, Smith DM, et al. Reminders to physicians from an introspective computer medical record: a two-year randomized trial. Ann Intern Med. 1984;100:130–8.
Davis JE, Meyer DL, Love RR. Cancer prevention activities in primary care group practice: physician estimates, physician performance, and the structure of practice. Submitted Med. Care.
Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Med Care. 1986;24:659–66.
Winickoff RN, Coltin K, Morgan MM, Buxbaum RC, Barnett GO. Improving physician performance through peer comparison feedback. Med Care. 1984;22:527–34.
Duggan AK. Analysis of the concordance between provider performance and recording [dissertation]. Baltimore, MD: The Johns Hopkins University, 1985.
Schulman J, Wood C. Flow sheets for charts of ambulatory patients. JAMA. 1971;217:933–7.
Starfield B, Simborg D, Johns C, Horn S. Coordination of care and its relationship to continuity and medical records. Med Care. 1977;15:929–38.
Williamson J. Continuing education and patient care research: physician response to screening test results. JAMA. 1967;201:118–22.
Wooliscroft JO, Calhoon JG, Billiu GA, Beauchamp C. Medical student attention to preventive medicine: change with time and reinforcement. Am J Prev Med. 1988;4:166–71.
Bouchard RE, Tufo HM, Beaty HN. The impact of a quality assurance program on postgraduate training in internal medicine. JAMA. 1985;253:1146–50.
Nelson GE, Graves SM, Holland RR, Nelson JM, Ratner J, Weed LL. A performance-based method of student evaluation. J Med Educ. 1976;10:33–42.
Boekeloo B. Evaluation of strategies for increasing cholesterol management practices in inpatients [dissertation]. Baltimore, MD: The Johns Hopkins University, 1988.
Kern DE, Grayson M, Barker LR, et al. Residency training in interviewing skills and the psychosocial domain of medical practice. J Gen Intern Med. 1989;4:421–31.
Whiting-O’Keefe QE, Henke C, Simborg DW. Choosing the correct unit of analysis in medical care experiments. Med Care. 1984;22:1101–13.
Linn BS. Continuing medical education: impact on emergency room burn care. JAMA. 1980;244:565–70.
Martin AR, Wolfe MA, Thibodeau LA, Dzau V, Braunwald E. A trial of two strategies to modify the test-ordering behavior of medical residents. N Engl J Med. 1980;303:1330–6.
Sanazaro PJ, Worth RM. Concurrent quality assurance in hospital care: report of a study by private initiative in PSRO. N Engl J Med. 1978;298:1171–7.
Bennett SE, Goodson JD, Izem E, et al. Comparing ambulatory care practices of primary care and traditional medicine residents. Med Care. 1985;23:816–22.
Ramsdell JW, Berry CC. Evaluation of general and traditional internal medicine residents utilizing a medical records audit based on educational objectives. Med Care. 1983;21:1144–53.
Makuc DM, Fried IM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health. 1989;79:21–6.
Dickie GL, Bass MJ. Improving problem oriented medical records through self-audit. J Fam Pract. 1980;10:487–90.
Barker LR, Starfield B, Gross RJ, Kern DE, Levine D, Fishelman P. Recognition of information and coordination of ambulatory care by medical residents. Med Care. 1989;27(5):558–62.
Pinkerton RE, Tinanoff N, Williams JL, Tapp JT. Resident physician performance in a continuing education format: does newly acquired knowledge improve patient care? JAMA. 1980;244:2183–5.
Goldenberg K. Periodic health examination: comparison of residency programs and national recommendations. J Gen Intern Med. 1986;1:282–6.
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