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Quality of medical records of pediatric surgical patients: A comparative study of conventional medical records with check-list medical records
Quality of Medical Records of Pediatric Surgical Patients : A Comparative Study of Conventional Medical Records With Check-List Medical Records
By Chandrakant
P. Shah
S
OCIOECONOMIC AND TECHNICAL ADVANCES in the past 25 yr have changed the disability patterns of disease in children and, accordingly, have altered the type of health care required. For instance, the proportion of medical admissions into hospitals has decreased whereas the proportion of elective surgical admissions into pediatric units has increased. In a recent survey, Robinson et al. have shown that surgical patients in these units constitute about 60% of the admissions, approximately 40”/0 of which could qualify for surgical day care.l Surgeons and other hospital personnel who are providing episodic care to the child during the stay in hospital may not be aware of some aspects of the child’s medical and social history. Many of the records of surgical patients are inadequate in some way. Much useful information, (such as a bleeding tendency in the family, a drug allergy, or an adverse reaction to anesthesia), is often missing from the physician’s history. Furthermore, the introduction of surgical day care requires more information, not only about the patient but also about the patient’s family, and their ability to provide home care. In an attempt to rectify some of the deficiencies found in the records of surgical patients, two new forms were devised specifically for surgical pediatric cases: a simplified checklist history form for the collection of basic information from parents whose children are admitted to hospital for surgery; and a simplified check-list nurses’ record to collect postoperative information for the same patients. The aim of this paper is to report a comparison of the quality of conventional medical records with that of the new check-list forms. MATERIAL
This hospital The
study has
study
AND
was conducted at the Children’s 96 pediatric beds and is affiliated
was
composed
of two
phases:
the
METHODS
Hospital, Vancouver, with the University preliminary
phase
B. C., Canada. This of British Columbia. and
the
study
phase.
From Department of Pediatrics, University of British CoZumbia, Vancouver, Canadu. Children’s Hospitnl, Vancouver, B. C., Supported in part by the Board of Directors, Canada. Chandrakant P. Shah, M.B.B.S., D.C.H., M.R.C.P. (Glasgow), F.R.C.P. (Canada): Associate Professor, Deparfment of Preventive Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada; formerly Clinical Assistant Professor, Department of Pediafrics, University of British Columbia, Canada; Attending Stufl, Vancouver General Hospital, Vancouver, B. C., Canada; Visiting Specialist Staff, Children’s Hospital, Vuncouver, B. C., Canada; and Medical Director, Children’s Aid Society of Vancouver, 8. C., Canada 420
Journal of Pediatric
Surgery, Vol. 7, No. 4
(August-September),
1972
STUDY OF MEDICAL
Prefiminary
421
RECORDS
Phrase
This phase comprised three stages: (I) A review of the existing charts at the Children’s Hospital was undertaken. (2) A listing was made of the significant items that seemed to be necessary for the future recording of preadmission histories and postoperative progress. (3) The items were rated as to their significance. The listing ot items tar the preadmission history was sent to 60 pediatric surgical subspecialists and ten anesthetists. The listing of items for the nurses’ notes was sent to these surgeons and anesthetists as well as to 30 nursing supervisors respondents were asked to rate
who were dealing exclusively with children. The the items on an interval scale as to: important,
cornot
important, and no opinion. The response rate for all the respondents was 80%. The more highly rated of these items were used to devise a preadmission history form and a postoperative nurses’ notes form. * Items were selected for the forms if the respondents achieved a 70% consensus on any one item. Seventeen items were considered important enough by the surgeons and anesthetists to be included on the history forms. In the postoperative nurses’ notes five items were considered to be common for all surgical patients. The following is a list of surgical categories with their corresponding numbers of additional items considered to be important: hernia (six); orchidopexy (five); hernia and orchidopexy (seven); tonsillectomy and adenoidectomy (five) ; myringotomy and adenoidectomy (four); myringotomy (four); cystoscopy, panendoscopy, and meatomy (six): strabismus repair (five); change of cast (three); osteotomy (five); local excision of lesion (four); and dental extraction and repair (three). Based on the items on the history forms and on the nurses’ notes, a rating system was developed to measure the quality of the two hospital records. The items were listed as positively Definitions:
recorded,
negatively
recorded,
and not recorded.
Recording: A recording of an item existed if some mention of either the presence or the absence of the item considered to be important was made on the chart. Recording was further divided into positive and negative recording.
Positive recording is where the actual signs or symptoms were present and were recorded on a chart; for example, the presence of vomiting following anesthesia. Negntioe recording is where the actual signs or symptoms that were considered important were absent and this absence was recorded on a chart; for example, the absence of bleeding at the operation site following tonsillectomy. Nonrecording: If no mention was made of an item, either positive or negative, this constituted a nonrecording following anesthesia),
(for example,
no mention
of vomiting,
either
present
or absent,
Study Phase This phase constituted three successive 2-mo periods comprising a total time of 6 mo. The study population for each of the periods consisted of all the patients admitted to the Children’s Hospital under the 11 most common surgical diagnoses. This procedure, while keeping the number of diagnostic categories to a minimum, had the merit of including more than 80% of all surgical admissions to the hospital. Those patients undergoing cardiovascular surgery or neurosurgery and those whose hospital stay was longer than 5 days were excluded from the study.
Period I: This consisted of a 2-mo review of the patients of the study sample. This was done after the medical and nursing staff had been notified that a 2-mo review of records was being implemented. The charts were rated as to the number of recordings and nonrecordings with respect to the rating system formulated in the preliminary study phase. Period II: At this point, the new checklist forms were introduced into the hospital routine. They remained in circulation for 2 mo. As before, the charts were rated as to the number of recordings and nonrecordings with respect to the rating system. * Available
from author
on request.
422
CHANDRAKANT
Table 1. Numb&
Not Recorded
as a Percentage (Number
of Total Possible
P. SHAH
Recordings
at Risk*)
Study Period I
II
III
At
Not Re-
Risk
cord-
Per
ed
cent
At Risk (N = 312)t
Not Recorded
Per cent
At Risk (N = 295)t
Not Recorded
Per cent
(N =
209H
Hisiory Posioperaiive
3553 2132
2001 io73
56.3 50.6
5304 3163
954 369
16.0 11.6
5015 3002
2926 1514
56.3 50.4
Nurses’ Total
5665
3079
54.2
8467
1323
15.6
6017
4440
55.4
Notes
No statistically significant difference between periods I and III (X2 = 2.06; P >0.05) “At Risk” figure was obtained by number of charts reviewed multiplied by total number of items considered important for charting in history and postoperative nurses’ l
notes ior each operative category. *N denotes number of medical records
reviewed
during
each study period.
Period ZlZ: In this period, the new charting system was withdrawn and the hospital staff reverted to their own charting methods. A review was again carried out, this time without the knowledge of the hospital staff. The charts, now composed in the old style, were again rated. The data so obtained were transferred to IBM cards and then to magnetic tape, and processed using the IBM 360167 computer.
Derivation of the Match&d Sample It was hypothesized that Periods I and III would be similar and that there would be a difference in recording in Period II. Hence, comparisons were made between recorded and nonrecorded items on the history and the postoperative nurses’ notes for Periods I and III. They were found not to be significantly different (Table 1). As a result, the sample for Periods I and III were combined. The records of the children were matched for the combined sample of Periods I and III (control) and of Period II (experimental). The order of priority for matching was: (1) operation (this was always matched exactly); (2) age (as closely as possible, from f 2 mo for infants to 1 2 yr for older teenagers); (3) sex (if matching was possible after matching for 1 and 2); (4) type of physician (if matching was possible after matching for 1, 2, and 3); and (5) diagnoses (if matching was possible after matching for 1, 2, 3, and 4). The analysis of these matched samples is reported in this paper. RESULTS
A description df the total matched sample is as folldks: Patients uedergoing five operations comprised 75% of the total matched sample (where there were 11 possible procedures). The most common operative procedures were local excision of lesion (25.4%), teeth extraction and repair (16.4%), tonsillectomy and adenoidectomy (16.1%), strabismus repair (KY%), and myringotomy (8.4%). Approximately 29% of children were under the age of 5 yi and 42% befween the ages of 5 and 9 yr; about 57% of these were male. 1~ about 56.5% of the cases, the status of their physicians was listed as Active Staff. For each of the items on the history form and on the postoperative nurses’ record, the number of nonrecordings for that item was calculated. These results are summarized in Table 2. It is apparent that the percentage of nonrecordings is significantly less in the experimental group than in the control group, whereas the reverse was true for negative recordings.
STUDY OF MEDICAL
423
RECORDS
Table 2. Total Number
of Recordings,
Matched
Sample Postoperative Nurses’ Notes
History Experimental %
Control %
(N =
3’JW Experimental %
11.4
(N=XW Control %
No recordings
57.0
17.9
48.9
Positive
22.9
28.6
18.8
19.5
20.1
53.6
18.0
45.2
Negative
recordings recordings
0.0 0.0 0.0 0.0 X* = 1846 (P
Positive and negative recordings Not applicable N*=
total number
of recordings
in history
or postoperative
19.6 10.2 4.3 4.0 x2 = 1157 (P
notes.
Tables 3 and 4 show the comparison of the control and the experimental groups with respect to the 11 operative categories. The percentage of nonrecordings with the old history forms was 57%; with the new forms it was 17.9%. There was a reduction of 78% in the number of nonrecordings for patients undergoing hernia repair and orchidotomy. The percentage of nonrecordings with the old nurses’ notes was 48.9%; with the new notes it was 11.4%. In the nurses’ notes, the incidence of nonrecordings for patients undergoing cystoscopy was reduced by 55%. It was again seen that the new form presented a substantial reduction in nonrecordings with concomitant increase especially negative recordings. Positive recordings in actual recordings, showed a moderate overall increase when the new check list was used. DISCUSSION
In spite of their incompleteness, statistics derived from the medical records of inpatient treatment in hospitals are likely to continue, on a national scale, to be the principal source of morbidity data.2 The inadequacy of these medical records has been recognized by the Hospital Accreditation Committee when reviewing hospital records, by research workers when trying to collect retrospective data, and, above all, by physicians and nurses when providing ongoing patients care.34 It is evident from the foregoing that the old history forms and nurses’ notes were incomplete and that viable alternatives are possible. This study has shown that the use of the new forms for the history and the nurses’ notes leads to a substantially decreased incidence of nonrecordings with a concomitant increase in the incidence of positive and negative recordings. It should be emphasized that this study was conducted on a sample population of surgical pediatric patients whose times for hospitalization were under 5 days, and that cardiovascular and neurosurgical patients were excluded. Despite these restrictions, the sample included more than 80% of the surgical admissions to the Children’s Hospital. When one reviews the surgical patients at the community hospital level, it is found that 95% of the patients remained in the hospital under 5 days .7 With the advent of day-care surgery and with the introduction of family participation units, which together cover 80”h of surgical admissions,’ greater onus will be placed upon the parents of the surgical child to supply information about their child’s preoperative history and
424
CHANDRAKANT
Table 3. Comparison of Control and Experimental Type of Recording for Each Operation Percentage
Groups Group
in History
of Recordings
Control Operation
Tonsillectomy
P. SHAH
Exoerimental
Total Possible Recordings
No’ Recording
Positive Recording
Negative Recording
No Recording
Positive Recording
Negative Recording
816
58.5
24.6
16.9
18.4
29.8
52.0
238
54.6
3.4
22.8
35.3
35.7 23.9
60.9
55.3
26.9 21.9
18.5
425 442
57.2
25.8
17.0
14.7
28.3
57.0
and
adenoidectomy Myringotomy and adenoidectomy Myringotomy Strabismus repair
35.8
Cystoscopy, panendoscopy, meatotomy Hernia repair Hernia repair and orchiopexy Local excision of lesion Teeth extraction and repair Change of cast Osteotomy Total
187
60.7
20.3
18.7
29.9
31 .o
39.0
408
68.1
16.4
15.4
16.4
16.2
67.4
51
80.4
17.6
2.0
2.0
35.3
62.7
1292
57.7
21.1
17.3
17.3
29.3
53.5
833 119 272
49.5 52.9
25.6 21.8
25.0 25.2
12.7 31.9
27.1 31 .l
60.1 37.0
54.8 57.0
24.3 22.9
21.0 20.1
16.5 17.9
34.2 28.6
49.3 53.6
5083
l For all operations, number of “no recordings” from number in experimental group (P
postoperative
have valuable
progress. Hence, applications.
a checklist
in control
form
group
significantly
for pediatric
patients
different
might
implications Several implications can be derived from this study. The maintenance of adequate charts is a facet of medical care frequently not carried out in even the largest hospitals, hospitals which, in theory, should be exemplary models to which all medical care facilities could aspire. In view of this fact, an improved charting technique would be a welcome change in all instances where day-to-day medical charting is required. With the introduction of the new check-list form, the quality of history taking and the charting of patients requiring surgery may be increased. To alleviate the apparent shortage of medical manpowerr8 ancillary medical personnel such as nurses’ aides, physicians’ assistants, and nurse physicians have been called upon to perform a variety of tasks.g This situation is particularly true at the community level where, because of staff shortages, skilled ancillary personnel must be utilized. lo It is not inappropriate to consider that having a check list for patient history and for postoperative nurses’ notes might guarantee both the recording of necessary information and the establishing of guidelines for what is to be recorded by these personnel. Undoubtedly related to the shortage of medical manpower is the increasing cost of
STUDY
OF MEDICAL
425
RECORDS
Table 4. Comparison
of Control and Experimental
in Postoperative Type of Recording
Groups
Nurses’ Notes
for Each Operation
Group
Percentage of Recordings Experimental
Control
Operation
Total No Possible ReRecord- cording ings
Positive Recording
Negative Recording
Positive & Negative Recording
N/A*
No Recording
Positive Recording
Negative Recording
Positive 8. Negative Recording
N/A’
Tonsillectomy and 480
53.5
15.2
19.2
12.1
0.0
9.0
16.5
47.3
27.3
0.0
and adenoidectomy Myringotomy
182 225
56.0 55.6
11.5 15.6
14.8 13.3
9.9 5.8
7.7 9.8
14.8 19.6
12.6 23.1
46.7 36.0
19.2 10.2
6.6 11.1
Strabismus repair
260
49.6
20.0
14.6
10.0
5.8
13.8
23.8
33.8
21.9
6.5
132 288
68.9 45.5
15.2 20.1
12.9 21.2
3.0 7.3
0.0 5.9
13.6 16.3
20.5 20.8
53.8 46.2
7.6 11.1
4.5 5.6
43.6t
23.1
23.1
5.1
5.1
25.6
20.5
33.3
15.4
5.1
760
40.5
24.1
19.3
10.9
5.1
7.2
2.1
44.6
21.2
5.9
and repair
441
56.2
17.5
16.1
10.0
6.2
7.3
19.0
54.0
19.7
0.0
Change of cast Osteotomy Total
56 176 3039
39.3t 32.4 48.9
21.4 18.2 18.8
30.4 21.6 18.0
3.6 22.7 10.2
5.4 5.1 4.0
28.6 10.2 11.4
16.1 15.9 19.5
44.6 42.6 45.2
10.7 27.3 19.6
0.0 4.3 4.3
adenoidectomy
Myringotomy
Cystoscopy. panendoscopy, meatotomy Hernia repair Hernia repair and ochiopexy Local excision of lesion Teeth extraction
39
t Not significantly different from number of “no recordings” others significantly different (P
in experimental
group. All
l1 This means that, for the greatest efficiency, the entire hospital staff must be utilized to their fullest capabilities.12 The use of the new forms might permit skilled hospital staff to be released for more complex duties. The new forms, because of their check-list design, readily lend themselves to the computer recording of data in so far as history records and nurses’ notes of surgical patients are concerned. This would appear to be a major improvement in view of the advantages embodied in this concept: the practicability of longitudinal research studies and the ability for the rapid retrieval of data on a patient at any time. The implementation of a new system is often resented by professionals involved. In the present study many of the nursing professionals objected to the check-list type of form. The nurses were informed about the results of the study in detail and were told that the time taken for charting under the new hospitalization.
426
CHANDRAKANT
P. SHAH
group sesand old systems was almost the same. r3 There were also informal sions about the quality of medical records. All these have led to the utilization of a new charting system in the study hospital. Now the nurses not only like the new system, but overwhelminglv endorse it. What is needed most for the improvement in the qualitv of medical records is a periodic educational programme for the systematic charting of patient information to all health professionals. SUMMARY
This study was undertaken to compare the qualities of the conventional charting procedure with that of the proposed check-list design. The sample population studied was composed of surgical pediatric patients whose time of hospitalization was under 5 days and who were not undergoing cardiovascular or neurosurgery. The number of nonrecordings with the new design was reduced, in some cases, by almost SO%, and by an average of 37%. The improved medical charts may be used to advantage on computer programming, in cases of day-care surgery, and in medical recording in general. ACKNOWLEDGMENT The author would like to thank the Board of Directors, Children’s Hospital, J. A. Short, Dr. H. T. Davenport, Dr. G. C. Robinson, Miss E. M. Eastley, K. Hutchinson, and J. Macdonnell for their assistance in the study, and for the invaluable contribution of study nurses, Mrs. at Children’s The
author
H. S. Henderson, Hospital. would
surgeons, anesthetists, for their cooperation
also
like
Mrs.
K. Bouressa,
to thank
Miss
and nursing supervisors in the study.
Mrs. C.
N. Grey,
Kinnis
of pediatric
for
and all the nursing statistical
hospitals
across
assistance,
staff and
North America
REFERENCES 1. Robinson, G. C., Shah, C. P., Argue, Corinne, Kinnis, Claire, and Israels, Sydney: A study of the need for alternative types of health care for children in hospitals. Pediatrics 43 ~866, 1969. 2. Watts, S. P., and Acheson, E. D.: Computer method for deriving hospital inpatient morbidity statistics based on the person as the unit. Brit. Med. J. 4:476, 1967. 3. Weed, L. L.: Medical records that guide and teach. New Eng. J. Med., 278:593, 1968. 4. Healy, E. E., and McGurk, W.: Effectiveness and acceptance of nurses’ notes. Nurs. Outlook, p. 32, Mar. 1966. 5. Gordon, B. L.: Preciseness and specificity for medical records. JAMA, 197:569, 1966. 6. Trainter, P. E., and Whalen, R. P.: Evaluation of quality of infant medical records. New York J. Med. 67:1911, 1967. 7. Robinson, G. C., Tonkin, R. S., Kinnis, C., and Shah, C. P.: A study of pediatric bed utilization and some implications for
regional planning. Brit. Columbia Med. J. 13:12:289, 1971. 8. Fuch, V. R.: The growing demand for medical care. New Eng. J. Med. 279 :190, 1968. 9. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 3, 1970, p. 55. 10. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 2, 1970, p. 38. 11. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 1, 1970, p. 9. 12. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 1, 1970, p. 66. 13. Shah, C. P., Davenport, H. T., and Henderson, S.: A time motion study of a nurse before and after the introduction of check-list type of postoperative nurses’ notes. Unpublished.
By Chandrakant
P. Shah
S
OCIOECONOMIC AND TECHNICAL ADVANCES in the past 25 yr have changed the disability patterns of disease in children and, accordingly, have altered the type of health care required. For instance, the proportion of medical admissions into hospitals has decreased whereas the proportion of elective surgical admissions into pediatric units has increased. In a recent survey, Robinson et al. have shown that surgical patients in these units constitute about 60% of the admissions, approximately 40”/0 of which could qualify for surgical day care.l Surgeons and other hospital personnel who are providing episodic care to the child during the stay in hospital may not be aware of some aspects of the child’s medical and social history. Many of the records of surgical patients are inadequate in some way. Much useful information, (such as a bleeding tendency in the family, a drug allergy, or an adverse reaction to anesthesia), is often missing from the physician’s history. Furthermore, the introduction of surgical day care requires more information, not only about the patient but also about the patient’s family, and their ability to provide home care. In an attempt to rectify some of the deficiencies found in the records of surgical patients, two new forms were devised specifically for surgical pediatric cases: a simplified checklist history form for the collection of basic information from parents whose children are admitted to hospital for surgery; and a simplified check-list nurses’ record to collect postoperative information for the same patients. The aim of this paper is to report a comparison of the quality of conventional medical records with that of the new check-list forms. MATERIAL
This hospital The
study has
study
AND
was conducted at the Children’s 96 pediatric beds and is affiliated
was
composed
of two
phases:
the
METHODS
Hospital, Vancouver, with the University preliminary
phase
B. C., Canada. This of British Columbia. and
the
study
phase.
From Department of Pediatrics, University of British CoZumbia, Vancouver, Canadu. Children’s Hospitnl, Vancouver, B. C., Supported in part by the Board of Directors, Canada. Chandrakant P. Shah, M.B.B.S., D.C.H., M.R.C.P. (Glasgow), F.R.C.P. (Canada): Associate Professor, Deparfment of Preventive Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada; formerly Clinical Assistant Professor, Department of Pediafrics, University of British Columbia, Canada; Attending Stufl, Vancouver General Hospital, Vancouver, B. C., Canada; Visiting Specialist Staff, Children’s Hospital, Vuncouver, B. C., Canada; and Medical Director, Children’s Aid Society of Vancouver, 8. C., Canada 420
Journal of Pediatric
Surgery, Vol. 7, No. 4
(August-September),
1972
STUDY OF MEDICAL
Prefiminary
421
RECORDS
Phrase
This phase comprised three stages: (I) A review of the existing charts at the Children’s Hospital was undertaken. (2) A listing was made of the significant items that seemed to be necessary for the future recording of preadmission histories and postoperative progress. (3) The items were rated as to their significance. The listing ot items tar the preadmission history was sent to 60 pediatric surgical subspecialists and ten anesthetists. The listing of items for the nurses’ notes was sent to these surgeons and anesthetists as well as to 30 nursing supervisors respondents were asked to rate
who were dealing exclusively with children. The the items on an interval scale as to: important,
cornot
important, and no opinion. The response rate for all the respondents was 80%. The more highly rated of these items were used to devise a preadmission history form and a postoperative nurses’ notes form. * Items were selected for the forms if the respondents achieved a 70% consensus on any one item. Seventeen items were considered important enough by the surgeons and anesthetists to be included on the history forms. In the postoperative nurses’ notes five items were considered to be common for all surgical patients. The following is a list of surgical categories with their corresponding numbers of additional items considered to be important: hernia (six); orchidopexy (five); hernia and orchidopexy (seven); tonsillectomy and adenoidectomy (five) ; myringotomy and adenoidectomy (four); myringotomy (four); cystoscopy, panendoscopy, and meatomy (six): strabismus repair (five); change of cast (three); osteotomy (five); local excision of lesion (four); and dental extraction and repair (three). Based on the items on the history forms and on the nurses’ notes, a rating system was developed to measure the quality of the two hospital records. The items were listed as positively Definitions:
recorded,
negatively
recorded,
and not recorded.
Recording: A recording of an item existed if some mention of either the presence or the absence of the item considered to be important was made on the chart. Recording was further divided into positive and negative recording.
Positive recording is where the actual signs or symptoms were present and were recorded on a chart; for example, the presence of vomiting following anesthesia. Negntioe recording is where the actual signs or symptoms that were considered important were absent and this absence was recorded on a chart; for example, the absence of bleeding at the operation site following tonsillectomy. Nonrecording: If no mention was made of an item, either positive or negative, this constituted a nonrecording following anesthesia),
(for example,
no mention
of vomiting,
either
present
or absent,
Study Phase This phase constituted three successive 2-mo periods comprising a total time of 6 mo. The study population for each of the periods consisted of all the patients admitted to the Children’s Hospital under the 11 most common surgical diagnoses. This procedure, while keeping the number of diagnostic categories to a minimum, had the merit of including more than 80% of all surgical admissions to the hospital. Those patients undergoing cardiovascular surgery or neurosurgery and those whose hospital stay was longer than 5 days were excluded from the study.
Period I: This consisted of a 2-mo review of the patients of the study sample. This was done after the medical and nursing staff had been notified that a 2-mo review of records was being implemented. The charts were rated as to the number of recordings and nonrecordings with respect to the rating system formulated in the preliminary study phase. Period II: At this point, the new checklist forms were introduced into the hospital routine. They remained in circulation for 2 mo. As before, the charts were rated as to the number of recordings and nonrecordings with respect to the rating system. * Available
from author
on request.
422
CHANDRAKANT
Table 1. Numb&
Not Recorded
as a Percentage (Number
of Total Possible
P. SHAH
Recordings
at Risk*)
Study Period I
II
III
At
Not Re-
Risk
cord-
Per
ed
cent
At Risk (N = 312)t
Not Recorded
Per cent
At Risk (N = 295)t
Not Recorded
Per cent
(N =
209H
Hisiory Posioperaiive
3553 2132
2001 io73
56.3 50.6
5304 3163
954 369
16.0 11.6
5015 3002
2926 1514
56.3 50.4
Nurses’ Total
5665
3079
54.2
8467
1323
15.6
6017
4440
55.4
Notes
No statistically significant difference between periods I and III (X2 = 2.06; P >0.05) “At Risk” figure was obtained by number of charts reviewed multiplied by total number of items considered important for charting in history and postoperative nurses’ l
notes ior each operative category. *N denotes number of medical records
reviewed
during
each study period.
Period ZlZ: In this period, the new charting system was withdrawn and the hospital staff reverted to their own charting methods. A review was again carried out, this time without the knowledge of the hospital staff. The charts, now composed in the old style, were again rated. The data so obtained were transferred to IBM cards and then to magnetic tape, and processed using the IBM 360167 computer.
Derivation of the Match&d Sample It was hypothesized that Periods I and III would be similar and that there would be a difference in recording in Period II. Hence, comparisons were made between recorded and nonrecorded items on the history and the postoperative nurses’ notes for Periods I and III. They were found not to be significantly different (Table 1). As a result, the sample for Periods I and III were combined. The records of the children were matched for the combined sample of Periods I and III (control) and of Period II (experimental). The order of priority for matching was: (1) operation (this was always matched exactly); (2) age (as closely as possible, from f 2 mo for infants to 1 2 yr for older teenagers); (3) sex (if matching was possible after matching for 1 and 2); (4) type of physician (if matching was possible after matching for 1, 2, and 3); and (5) diagnoses (if matching was possible after matching for 1, 2, 3, and 4). The analysis of these matched samples is reported in this paper. RESULTS
A description df the total matched sample is as folldks: Patients uedergoing five operations comprised 75% of the total matched sample (where there were 11 possible procedures). The most common operative procedures were local excision of lesion (25.4%), teeth extraction and repair (16.4%), tonsillectomy and adenoidectomy (16.1%), strabismus repair (KY%), and myringotomy (8.4%). Approximately 29% of children were under the age of 5 yi and 42% befween the ages of 5 and 9 yr; about 57% of these were male. 1~ about 56.5% of the cases, the status of their physicians was listed as Active Staff. For each of the items on the history form and on the postoperative nurses’ record, the number of nonrecordings for that item was calculated. These results are summarized in Table 2. It is apparent that the percentage of nonrecordings is significantly less in the experimental group than in the control group, whereas the reverse was true for negative recordings.
STUDY OF MEDICAL
423
RECORDS
Table 2. Total Number
of Recordings,
Matched
Sample Postoperative Nurses’ Notes
History Experimental %
Control %
(N =
3’JW Experimental %
11.4
(N=XW Control %
No recordings
57.0
17.9
48.9
Positive
22.9
28.6
18.8
19.5
20.1
53.6
18.0
45.2
Negative
recordings recordings
0.0 0.0 0.0 0.0 X* = 1846 (P
Positive and negative recordings Not applicable N*=
total number
of recordings
in history
or postoperative
19.6 10.2 4.3 4.0 x2 = 1157 (P
notes.
Tables 3 and 4 show the comparison of the control and the experimental groups with respect to the 11 operative categories. The percentage of nonrecordings with the old history forms was 57%; with the new forms it was 17.9%. There was a reduction of 78% in the number of nonrecordings for patients undergoing hernia repair and orchidotomy. The percentage of nonrecordings with the old nurses’ notes was 48.9%; with the new notes it was 11.4%. In the nurses’ notes, the incidence of nonrecordings for patients undergoing cystoscopy was reduced by 55%. It was again seen that the new form presented a substantial reduction in nonrecordings with concomitant increase especially negative recordings. Positive recordings in actual recordings, showed a moderate overall increase when the new check list was used. DISCUSSION
In spite of their incompleteness, statistics derived from the medical records of inpatient treatment in hospitals are likely to continue, on a national scale, to be the principal source of morbidity data.2 The inadequacy of these medical records has been recognized by the Hospital Accreditation Committee when reviewing hospital records, by research workers when trying to collect retrospective data, and, above all, by physicians and nurses when providing ongoing patients care.34 It is evident from the foregoing that the old history forms and nurses’ notes were incomplete and that viable alternatives are possible. This study has shown that the use of the new forms for the history and the nurses’ notes leads to a substantially decreased incidence of nonrecordings with a concomitant increase in the incidence of positive and negative recordings. It should be emphasized that this study was conducted on a sample population of surgical pediatric patients whose times for hospitalization were under 5 days, and that cardiovascular and neurosurgical patients were excluded. Despite these restrictions, the sample included more than 80% of the surgical admissions to the Children’s Hospital. When one reviews the surgical patients at the community hospital level, it is found that 95% of the patients remained in the hospital under 5 days .7 With the advent of day-care surgery and with the introduction of family participation units, which together cover 80”h of surgical admissions,’ greater onus will be placed upon the parents of the surgical child to supply information about their child’s preoperative history and
424
CHANDRAKANT
Table 3. Comparison of Control and Experimental Type of Recording for Each Operation Percentage
Groups Group
in History
of Recordings
Control Operation
Tonsillectomy
P. SHAH
Exoerimental
Total Possible Recordings
No’ Recording
Positive Recording
Negative Recording
No Recording
Positive Recording
Negative Recording
816
58.5
24.6
16.9
18.4
29.8
52.0
238
54.6
3.4
22.8
35.3
35.7 23.9
60.9
55.3
26.9 21.9
18.5
425 442
57.2
25.8
17.0
14.7
28.3
57.0
and
adenoidectomy Myringotomy and adenoidectomy Myringotomy Strabismus repair
35.8
Cystoscopy, panendoscopy, meatotomy Hernia repair Hernia repair and orchiopexy Local excision of lesion Teeth extraction and repair Change of cast Osteotomy Total
187
60.7
20.3
18.7
29.9
31 .o
39.0
408
68.1
16.4
15.4
16.4
16.2
67.4
51
80.4
17.6
2.0
2.0
35.3
62.7
1292
57.7
21.1
17.3
17.3
29.3
53.5
833 119 272
49.5 52.9
25.6 21.8
25.0 25.2
12.7 31.9
27.1 31 .l
60.1 37.0
54.8 57.0
24.3 22.9
21.0 20.1
16.5 17.9
34.2 28.6
49.3 53.6
5083
l For all operations, number of “no recordings” from number in experimental group (P
postoperative
have valuable
progress. Hence, applications.
a checklist
in control
form
group
significantly
for pediatric
patients
different
might
implications Several implications can be derived from this study. The maintenance of adequate charts is a facet of medical care frequently not carried out in even the largest hospitals, hospitals which, in theory, should be exemplary models to which all medical care facilities could aspire. In view of this fact, an improved charting technique would be a welcome change in all instances where day-to-day medical charting is required. With the introduction of the new check-list form, the quality of history taking and the charting of patients requiring surgery may be increased. To alleviate the apparent shortage of medical manpowerr8 ancillary medical personnel such as nurses’ aides, physicians’ assistants, and nurse physicians have been called upon to perform a variety of tasks.g This situation is particularly true at the community level where, because of staff shortages, skilled ancillary personnel must be utilized. lo It is not inappropriate to consider that having a check list for patient history and for postoperative nurses’ notes might guarantee both the recording of necessary information and the establishing of guidelines for what is to be recorded by these personnel. Undoubtedly related to the shortage of medical manpower is the increasing cost of
STUDY
OF MEDICAL
425
RECORDS
Table 4. Comparison
of Control and Experimental
in Postoperative Type of Recording
Groups
Nurses’ Notes
for Each Operation
Group
Percentage of Recordings Experimental
Control
Operation
Total No Possible ReRecord- cording ings
Positive Recording
Negative Recording
Positive & Negative Recording
N/A*
No Recording
Positive Recording
Negative Recording
Positive 8. Negative Recording
N/A’
Tonsillectomy and 480
53.5
15.2
19.2
12.1
0.0
9.0
16.5
47.3
27.3
0.0
and adenoidectomy Myringotomy
182 225
56.0 55.6
11.5 15.6
14.8 13.3
9.9 5.8
7.7 9.8
14.8 19.6
12.6 23.1
46.7 36.0
19.2 10.2
6.6 11.1
Strabismus repair
260
49.6
20.0
14.6
10.0
5.8
13.8
23.8
33.8
21.9
6.5
132 288
68.9 45.5
15.2 20.1
12.9 21.2
3.0 7.3
0.0 5.9
13.6 16.3
20.5 20.8
53.8 46.2
7.6 11.1
4.5 5.6
43.6t
23.1
23.1
5.1
5.1
25.6
20.5
33.3
15.4
5.1
760
40.5
24.1
19.3
10.9
5.1
7.2
2.1
44.6
21.2
5.9
and repair
441
56.2
17.5
16.1
10.0
6.2
7.3
19.0
54.0
19.7
0.0
Change of cast Osteotomy Total
56 176 3039
39.3t 32.4 48.9
21.4 18.2 18.8
30.4 21.6 18.0
3.6 22.7 10.2
5.4 5.1 4.0
28.6 10.2 11.4
16.1 15.9 19.5
44.6 42.6 45.2
10.7 27.3 19.6
0.0 4.3 4.3
adenoidectomy
Myringotomy
Cystoscopy. panendoscopy, meatotomy Hernia repair Hernia repair and ochiopexy Local excision of lesion Teeth extraction
39
t Not significantly different from number of “no recordings” others significantly different (P
in experimental
group. All
l1 This means that, for the greatest efficiency, the entire hospital staff must be utilized to their fullest capabilities.12 The use of the new forms might permit skilled hospital staff to be released for more complex duties. The new forms, because of their check-list design, readily lend themselves to the computer recording of data in so far as history records and nurses’ notes of surgical patients are concerned. This would appear to be a major improvement in view of the advantages embodied in this concept: the practicability of longitudinal research studies and the ability for the rapid retrieval of data on a patient at any time. The implementation of a new system is often resented by professionals involved. In the present study many of the nursing professionals objected to the check-list type of form. The nurses were informed about the results of the study in detail and were told that the time taken for charting under the new hospitalization.
426
CHANDRAKANT
P. SHAH
group sesand old systems was almost the same. r3 There were also informal sions about the quality of medical records. All these have led to the utilization of a new charting system in the study hospital. Now the nurses not only like the new system, but overwhelminglv endorse it. What is needed most for the improvement in the qualitv of medical records is a periodic educational programme for the systematic charting of patient information to all health professionals. SUMMARY
This study was undertaken to compare the qualities of the conventional charting procedure with that of the proposed check-list design. The sample population studied was composed of surgical pediatric patients whose time of hospitalization was under 5 days and who were not undergoing cardiovascular or neurosurgery. The number of nonrecordings with the new design was reduced, in some cases, by almost SO%, and by an average of 37%. The improved medical charts may be used to advantage on computer programming, in cases of day-care surgery, and in medical recording in general. ACKNOWLEDGMENT The author would like to thank the Board of Directors, Children’s Hospital, J. A. Short, Dr. H. T. Davenport, Dr. G. C. Robinson, Miss E. M. Eastley, K. Hutchinson, and J. Macdonnell for their assistance in the study, and for the invaluable contribution of study nurses, Mrs. at Children’s The
author
H. S. Henderson, Hospital. would
surgeons, anesthetists, for their cooperation
also
like
Mrs.
K. Bouressa,
to thank
Miss
and nursing supervisors in the study.
Mrs. C.
N. Grey,
Kinnis
of pediatric
for
and all the nursing statistical
hospitals
across
assistance,
staff and
North America
REFERENCES 1. Robinson, G. C., Shah, C. P., Argue, Corinne, Kinnis, Claire, and Israels, Sydney: A study of the need for alternative types of health care for children in hospitals. Pediatrics 43 ~866, 1969. 2. Watts, S. P., and Acheson, E. D.: Computer method for deriving hospital inpatient morbidity statistics based on the person as the unit. Brit. Med. J. 4:476, 1967. 3. Weed, L. L.: Medical records that guide and teach. New Eng. J. Med., 278:593, 1968. 4. Healy, E. E., and McGurk, W.: Effectiveness and acceptance of nurses’ notes. Nurs. Outlook, p. 32, Mar. 1966. 5. Gordon, B. L.: Preciseness and specificity for medical records. JAMA, 197:569, 1966. 6. Trainter, P. E., and Whalen, R. P.: Evaluation of quality of infant medical records. New York J. Med. 67:1911, 1967. 7. Robinson, G. C., Tonkin, R. S., Kinnis, C., and Shah, C. P.: A study of pediatric bed utilization and some implications for
regional planning. Brit. Columbia Med. J. 13:12:289, 1971. 8. Fuch, V. R.: The growing demand for medical care. New Eng. J. Med. 279 :190, 1968. 9. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 3, 1970, p. 55. 10. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 2, 1970, p. 38. 11. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 1, 1970, p. 9. 12. Task Force Reports on the Cost of Health Services in Canada. Ottawa, Queen’s Printer, No. 1, 1970, p. 66. 13. Shah, C. P., Davenport, H. T., and Henderson, S.: A time motion study of a nurse before and after the introduction of check-list type of postoperative nurses’ notes. Unpublished.