Traditional Hospital Records as a Source of Clinical Data in the Outpatient Setting

Reference: Tang, P. C.; Fafchamps, D.; & Shortliffe, E. H. Traditional Hospital Records as a Source of Clinical Data in the Outpatient Setting. Knowledge Systems Laboratory, November, 1994.

Abstract: Objective: To determine the success with which physicians find patient information using traditional hospital records as the source of data when making clinical decisions in ambulatory care. Further, to characterize the patient information sought by physicians during routine outpatient visits. Design: Observational study. Setting: Internal medicine clinic at a university hospital. Participants: Residents (27), faculty physicians (13), nurses (3), and clerical staff (4). Measurements: We recorded 168 consecutive patient cases presented to attending physicians by internal medicine residents. We analyzed transcripts to identify questions indicating that the physicians could not find patient information in the medical record. We performed thematic analysis to generate a set of prototypical questions asked by physicians regarding patient information. Results: In 136 of 168 (81 percent) cases, physicians could not find all the patient information that they desired during a patient's visit. We documented 538 instances of patient information that could not be drived from the hospital chart, 370 (69 percent) of which involved data generated at the same institution where the patient was being seen. Patient- information queries were grouped into 15 prototypical queries. Conclusions: The multi-authored medical record system we studied did not provide effective access to patient information for physicians making clinical decisions in an outpatient setting. Improved methods for addressing prototypical questions arising in routine practice are needed.

Notes: Updated November 1994.

Jump to... [KSL] [SMI] [Reports by Author] [Reports by KSL Number] [Reports by Year]
Send mail to: ksl-info@ksl.stanford.edu to send a message to the maintainer of the KSL Reports.