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Strategies for using chart audit
Viewpoint Strategies for U s i n g Chart A u d i t JoAnne Herman, PhD, RN The goal of all healthcare providers is to deliver effective care that has a sound scientific basis. This scientific base is established through research. While health professionals caring for clients with HIV/AIDS have benefited from research findings, they also have been frustrated by the lack of practical research findings to guide practice. In the absence of research-based guidelines for practice, expert clinicians draw on experience and critical thinking skills to develop unique and often quite effective treatments and interventions for HIV/AIDS clients. These interventions, treatments, client reactions, and outcomes are lost to other health care professions because this knowledge is stored in client records and not readily available. One method to retrieve this valuable information is chart audit, the process of systematically identifying and collecting clinical data that are recorded as part of a formal documentation system. Any institution or organization where records are kept on client contact and care is a rich source of data. Data obtained from chart audit can be used to evaluate efficacy of specific treatments or interventions, identify problems that need solutions, generate hypotheses for research, or explore relationships among variables. For example, Moore and Chaisson (1996) recently published an article that used chart audit to investigate the relationship between preventive drug therapies and opportunistic infections in HIV-infected clients with CD4+ counts below 300mm 3. The ultimate goal of chart audit is to generate clinical knowledge that can be used to improve the care provided for clients living with HIV/AIDS. To assure that the clinical knowledge is accurate, data obtained from chart audit must meet appropriate standards of rigor. One of the basic principles is that decisions about data are made a priori or before data collection. This principle assures that sources of bias are minimized as much as possible. When sources of bias are controlled, clinicians can have confidence in the findings and feel comfortable applying the knowledge in care of clients. The purpose of this presentation is to describe the a priori decisions necessary when using chart audit to obtain clinical data. JANAC
Vol. 7, No. 6, November-December, 1996
What Data do I Want to Collect? The answer to this question has three parts: What is the question I am trying to answer, what information do I need to collect in order to answer the question, and how will I identify the information in the client record?
Posing the Question The first step in the process of performing a chart audit is to develop the question because the question guides all future decisions. There are a number of methods you can use to develop the question. The most important source of information is your own expertise and experience or that of your colleagues. Practitioners often identify problems that need solutions, apply unique solutions to problems, or formulate hunches about relationships among variables. The experiences of clinicians are a rich source of clinical questions. Another method is to review literature to find out the current state of knowledge in your area of interest. Often authors will identify gaps in knowledge that require attention. These statements provide valuable guidance as you select the question. After reading articles, you may identify areas where more knowledge is essential.
Selecting the Variables The next step is to decide what information is necessary to answer the question. Information contained in client records is voluminous, so the process of selecting the variables of interest can be difficult. You could easily find yourself overwhelmed by the mass of information from which you have to choose. In addition, chart audit is much more time consuming than it might seem. The piinciple here is to collect the minimum number of variables required to answer the question (Findley & Daum, 1989). One way to help keep your thinking organized is to write the question on an index card and keep this card in sight as y o u make decisions about i n f o r m a t i o n to include. With the question in mind, ask yourself two 69
Viewpoint
things: Is this information required in order to answer the question, and is this information vital to the interpretation of the findings? The mlswer to the first question is easy if you keep your question in mind. Perhaps the answer to the second question is not so obvious. For example, the question m a y involve the relationship between the number of CD4+ cells and fatigue. Age is not necessary to answer the question. However, age is important in the interpretation of the findings. Therefore, it is necessary for age to be included 'in the data collection. This second category of information is the most challenging to identify and will require some careful thought. After you have determined the information you want to collect, you need to consider the pragmatics of the situation. Are the data routinely recorded in the client record? The key term here is routinel)a You must select data that are recorded consistentl~ An easy way to determine if data are recorded is to do a quick search of 10 records. The data should be found in nine of the 10 records. If the data you want are not routinely recorded, try to identify another source for the data in the client record. Next, ask yourself, How much confidence do I have in the quality of the data? Data obtained from laboratory tests as well as information such as weight, temperature, and blood pressure are useful because they are collected u s i n g s t a n d a r d i z e d m e a s u r e m e n t techniques. Descriptions of clients' symptoms, reactions to treatments, side effects from drugs, activities of daily life, and health promotion behaviors are all valuable sources of information to be collected in a chart audit. This information can be collected by creating a coding system so the descriptions from the records can be summarized in a systematic way. This strategy will assure that the information is accurate. The most important element of using chart audit is the accuracy of the data. Accuracy is important because it will influence the outcomes associated with any intervention or conclusion developed from the data. When using data that were collected and recorded by someone else, there is always a question about the quality and 70
accuracy of the data. For all information found in the record, you must make a judgment as to the perceived accuracy of the data. Do not include data that you know or suspect are inaccurate. If the analysis described above results in the identification of questionable data, here are some strategies to use: Revise or change the question so that it is appropriate for available data. Identify alternative sources of data about a single variable. Collect data about one variable from more than one entry in the record. Use the original source of information. Defining the Variables Accuracy of data is determined not only by source quality but also by collection quality. To have confidence in the data, you must collect the data consistently and reliably from every record. That is, all data concerning the variable need to be extracted in exactly the same w a y for each record. The mechanism for assuring collection quality is to define the specific attributes that make up each variable. The more specific the definition, the more reliable the data. The definition should be specific enough so that the data collector can consistently identify the data that is to be collected from the record. For example, you could be interested in weight. This variable is recorded numerous times in a record. Which entry or entries do you mean when identifying the variable of weight? The definition might be "the subject's weight in pounds recorded before each clinic visit from May to August 1996." This definition excludes selfreport of weight, weight obtained during a hospitalization, and weights obtained before May 1, 1996 and after Aug. 31, 1996. This definition allows the data collector to reliably extract the data.
How do I Collect the Data? Now that you have decided on the question, determined the variables, and established the definitions, it is time to identify the records to be reviewed and collect the data. JANAC
Vol. 7, No. 6, November-Decembe~ 1996
Identifying the Records to be R e v i e w e d
The question you developed at the beginning of the chart audit process determines selection of records. You want to select from a pool of client records that match your question. To do this, you create a list of inclusion criteria. The inclusion criteria describe what characteristics a record must have in order to be eligible to be included in the review. Once the inclusion criteria have been established, you select records from this pool. The most valued m e t h o d of selecting records is by r a n d o m selection (Findley & Daum, 1989). This means that every record with the established characteristics has an equal opportunity to be reviewed. Use a table of random numbers or some predetermined scheme that will assure every record has an opportunity to be selected. This process protects from bias so that there is not any inclusion or exclusion of particular records that would affect the findings. After a record has been selected, you may find that it does not have some of the characteristics necessary to provide the needed data or the record is different in some way from the other records that you are reviewing. The record might need to be eliminated from the review. However, be careful about eliminating records. You could be introducing bias by the choices you make. The way to protect against this bias is to determine a set of decision rules before beginning data collection. Think about the problems a record might have that would necessitate elimination. Write these decision rules down and follow them as you review charts. Creating the Data Collection Instrument
You can save yourself a lot of time and frustration if you carefully plan the data collection instrument. Lay out the instrument so the items match the sequence in which the data occur in the record. It is very time consuming to flip back and forth in a record looking for data. Create the instrument with the analysis in mind. If you are going to use a computer to analyze the data, you want to collect the data exactly as you will put them in the computer. If you are planning on categorizing data, put the categories JANAC Vol. 7, No. 6, November-December, 1996
on the instrument. The data collector can check the appropriate category rather than having to transpose those data when they are entered into the computer. Software is available to create your own instrument that is a bubble sheet appropriate for scanning into the computer. Using this technology, you will be able to prepare data for entry into the computer simultaneously with actual data collection. If you do not have access to one of these new programs, the data collection instrument needs to be created so that it is easy and efficient to transfer to a computer. As you are creating the data collection instrument, plan for ways to include the coding definitions for variables and decision rules for exclusion of a record. You have spent a lot if time thinking ahead about potential dilemmas and developing rules to guide the data collection. This work is lost if it is not available to the data collector to use when the data actually are being extracted from the record. Including all this information on the actual data collection instrtanent could get pretty messy. Perhaps, attaching some a d d e n d u m sheets to accompany the instrument would be the appropriate choice. The last step before you begin data collection is to use the data collection instrument on a few records. You have put a lot of thought and preplanning into the selection and definition of variables, design of the instruments, and a priori decision rules hoping to manage every contingency. However, when you actually go to a record and begin collecting data, you m ay discover either major problems or minor revising that need attention. Even the most well-planned instrument will need fine tuning. The desire of all clinidans is to provide the very best care possible to clients with HIV/AIDS. If you follow the steps above, you will be able to collect data from client records in a systematic way and use the information to improve care and outcomes for clients with HIV/AIDS. The process of chart audit requires creativity, attention to detail, preplanning, and consistent follow through. However, the effort is worth it because client records are a valuable source of information that clinidans can apply in their clinical practice. 71
Viewpoint
References
Certification Examination in HIV/AIDS Nursing
Findley, T., & Daum, M. (1989). Research in physical medicine and rehabilitation: The chart review or how to use clinical data for exploratory retrospective studies. American Journal of Physical Medicineand Rehabilitation,68, 150-157. Moore, R., & Chaisson, R. (1996). Natural history of opportunistic disease in an HIV-infected urban clinical cohort. Annals of Internal Medicine, 124,633-642.
JoAnne Herman, PhD, RN,
is Associate Professor, College of Nursing, University of South Carolina, Columbia, SC.
Editor's note: There is an o n g o i n g need for nurses in HW/AIDS care to evaluate a n d i m p r o v e the quality of healthcare services provided to their clients. Chart audits provide a practical and effective w a y to achieve this goal. There is, however, limited information in the literature to assist clinicians in designing chart audits that generate a c c u r a t e a n d useful data. F r o m that p e r s p e c t i v e , Dr. H e r m a n has outlined in this column the basic steps and considerations that need to be addressed in understanding a chart audit. Hopefully, this discussion will assist direct care providers in organizing a n d disseminating the valuable information recorded in client records. In this issue an article e x a m i n i n g the d i a g n o s i s of H I V d e m e n t i a b y R o s e n b e r g a n d c o l l e a g u e s p r o v i d e s an example of h o w the chart audit can be a valuable tool in evaluating patient care and diagnostic procedures.
Certification examination April 5, 1997 Cost ANAC member: $200 Non-ANAC member: $280 The HIV/AIDS Nursing Certification Board (HANCB) is responsible for the development and administration of the Certification Program in HW/AIDS Nursing. It was established by ANAC to develop and administer the certification examination. Certification is a voluntary process through which the HANCB validates an individual RN's qualifications and knowledge in the specialized area of HW/AIDS nursing practice. RNs who complete the Certification Examination in HIV/AIDS Nursing will be entitled to indicate board certification status by using the letters ACRN. Eligibility. Current license as a RN in the United States (or the international equivalent) and at least two years of experience in clinical practice, education, management, or research in HW/AIDS nursing are recommended for eligibility to take the Certification Examination in HIV/AIDS Nursing. To obtain the Certification Examination in HIV/AIDS Nursing Handbook for Candidates and application, complete the form below and mail to: HW/AIDS Nursing Certification Board c/o Professional Testing Corp 1211 Ave. of the Americas/15th floor New York NY 10036 or call/fax: tel: 212/852 --0400 fax: 212/852 -0414 Name: Address: city
72
state
zip
JANAC Vol. 7, No. 6, November-Decembe~ 1996
Vol. 7, No. 6, November-December, 1996
What Data do I Want to Collect? The answer to this question has three parts: What is the question I am trying to answer, what information do I need to collect in order to answer the question, and how will I identify the information in the client record?
Posing the Question The first step in the process of performing a chart audit is to develop the question because the question guides all future decisions. There are a number of methods you can use to develop the question. The most important source of information is your own expertise and experience or that of your colleagues. Practitioners often identify problems that need solutions, apply unique solutions to problems, or formulate hunches about relationships among variables. The experiences of clinicians are a rich source of clinical questions. Another method is to review literature to find out the current state of knowledge in your area of interest. Often authors will identify gaps in knowledge that require attention. These statements provide valuable guidance as you select the question. After reading articles, you may identify areas where more knowledge is essential.
Selecting the Variables The next step is to decide what information is necessary to answer the question. Information contained in client records is voluminous, so the process of selecting the variables of interest can be difficult. You could easily find yourself overwhelmed by the mass of information from which you have to choose. In addition, chart audit is much more time consuming than it might seem. The piinciple here is to collect the minimum number of variables required to answer the question (Findley & Daum, 1989). One way to help keep your thinking organized is to write the question on an index card and keep this card in sight as y o u make decisions about i n f o r m a t i o n to include. With the question in mind, ask yourself two 69
Viewpoint
things: Is this information required in order to answer the question, and is this information vital to the interpretation of the findings? The mlswer to the first question is easy if you keep your question in mind. Perhaps the answer to the second question is not so obvious. For example, the question m a y involve the relationship between the number of CD4+ cells and fatigue. Age is not necessary to answer the question. However, age is important in the interpretation of the findings. Therefore, it is necessary for age to be included 'in the data collection. This second category of information is the most challenging to identify and will require some careful thought. After you have determined the information you want to collect, you need to consider the pragmatics of the situation. Are the data routinely recorded in the client record? The key term here is routinel)a You must select data that are recorded consistentl~ An easy way to determine if data are recorded is to do a quick search of 10 records. The data should be found in nine of the 10 records. If the data you want are not routinely recorded, try to identify another source for the data in the client record. Next, ask yourself, How much confidence do I have in the quality of the data? Data obtained from laboratory tests as well as information such as weight, temperature, and blood pressure are useful because they are collected u s i n g s t a n d a r d i z e d m e a s u r e m e n t techniques. Descriptions of clients' symptoms, reactions to treatments, side effects from drugs, activities of daily life, and health promotion behaviors are all valuable sources of information to be collected in a chart audit. This information can be collected by creating a coding system so the descriptions from the records can be summarized in a systematic way. This strategy will assure that the information is accurate. The most important element of using chart audit is the accuracy of the data. Accuracy is important because it will influence the outcomes associated with any intervention or conclusion developed from the data. When using data that were collected and recorded by someone else, there is always a question about the quality and 70
accuracy of the data. For all information found in the record, you must make a judgment as to the perceived accuracy of the data. Do not include data that you know or suspect are inaccurate. If the analysis described above results in the identification of questionable data, here are some strategies to use: Revise or change the question so that it is appropriate for available data. Identify alternative sources of data about a single variable. Collect data about one variable from more than one entry in the record. Use the original source of information. Defining the Variables Accuracy of data is determined not only by source quality but also by collection quality. To have confidence in the data, you must collect the data consistently and reliably from every record. That is, all data concerning the variable need to be extracted in exactly the same w a y for each record. The mechanism for assuring collection quality is to define the specific attributes that make up each variable. The more specific the definition, the more reliable the data. The definition should be specific enough so that the data collector can consistently identify the data that is to be collected from the record. For example, you could be interested in weight. This variable is recorded numerous times in a record. Which entry or entries do you mean when identifying the variable of weight? The definition might be "the subject's weight in pounds recorded before each clinic visit from May to August 1996." This definition excludes selfreport of weight, weight obtained during a hospitalization, and weights obtained before May 1, 1996 and after Aug. 31, 1996. This definition allows the data collector to reliably extract the data.
How do I Collect the Data? Now that you have decided on the question, determined the variables, and established the definitions, it is time to identify the records to be reviewed and collect the data. JANAC
Vol. 7, No. 6, November-Decembe~ 1996
Identifying the Records to be R e v i e w e d
The question you developed at the beginning of the chart audit process determines selection of records. You want to select from a pool of client records that match your question. To do this, you create a list of inclusion criteria. The inclusion criteria describe what characteristics a record must have in order to be eligible to be included in the review. Once the inclusion criteria have been established, you select records from this pool. The most valued m e t h o d of selecting records is by r a n d o m selection (Findley & Daum, 1989). This means that every record with the established characteristics has an equal opportunity to be reviewed. Use a table of random numbers or some predetermined scheme that will assure every record has an opportunity to be selected. This process protects from bias so that there is not any inclusion or exclusion of particular records that would affect the findings. After a record has been selected, you may find that it does not have some of the characteristics necessary to provide the needed data or the record is different in some way from the other records that you are reviewing. The record might need to be eliminated from the review. However, be careful about eliminating records. You could be introducing bias by the choices you make. The way to protect against this bias is to determine a set of decision rules before beginning data collection. Think about the problems a record might have that would necessitate elimination. Write these decision rules down and follow them as you review charts. Creating the Data Collection Instrument
You can save yourself a lot of time and frustration if you carefully plan the data collection instrument. Lay out the instrument so the items match the sequence in which the data occur in the record. It is very time consuming to flip back and forth in a record looking for data. Create the instrument with the analysis in mind. If you are going to use a computer to analyze the data, you want to collect the data exactly as you will put them in the computer. If you are planning on categorizing data, put the categories JANAC Vol. 7, No. 6, November-December, 1996
on the instrument. The data collector can check the appropriate category rather than having to transpose those data when they are entered into the computer. Software is available to create your own instrument that is a bubble sheet appropriate for scanning into the computer. Using this technology, you will be able to prepare data for entry into the computer simultaneously with actual data collection. If you do not have access to one of these new programs, the data collection instrument needs to be created so that it is easy and efficient to transfer to a computer. As you are creating the data collection instrument, plan for ways to include the coding definitions for variables and decision rules for exclusion of a record. You have spent a lot if time thinking ahead about potential dilemmas and developing rules to guide the data collection. This work is lost if it is not available to the data collector to use when the data actually are being extracted from the record. Including all this information on the actual data collection instrtanent could get pretty messy. Perhaps, attaching some a d d e n d u m sheets to accompany the instrument would be the appropriate choice. The last step before you begin data collection is to use the data collection instrument on a few records. You have put a lot of thought and preplanning into the selection and definition of variables, design of the instruments, and a priori decision rules hoping to manage every contingency. However, when you actually go to a record and begin collecting data, you m ay discover either major problems or minor revising that need attention. Even the most well-planned instrument will need fine tuning. The desire of all clinidans is to provide the very best care possible to clients with HIV/AIDS. If you follow the steps above, you will be able to collect data from client records in a systematic way and use the information to improve care and outcomes for clients with HIV/AIDS. The process of chart audit requires creativity, attention to detail, preplanning, and consistent follow through. However, the effort is worth it because client records are a valuable source of information that clinidans can apply in their clinical practice. 71
Viewpoint
References
Certification Examination in HIV/AIDS Nursing
Findley, T., & Daum, M. (1989). Research in physical medicine and rehabilitation: The chart review or how to use clinical data for exploratory retrospective studies. American Journal of Physical Medicineand Rehabilitation,68, 150-157. Moore, R., & Chaisson, R. (1996). Natural history of opportunistic disease in an HIV-infected urban clinical cohort. Annals of Internal Medicine, 124,633-642.
JoAnne Herman, PhD, RN,
is Associate Professor, College of Nursing, University of South Carolina, Columbia, SC.
Editor's note: There is an o n g o i n g need for nurses in HW/AIDS care to evaluate a n d i m p r o v e the quality of healthcare services provided to their clients. Chart audits provide a practical and effective w a y to achieve this goal. There is, however, limited information in the literature to assist clinicians in designing chart audits that generate a c c u r a t e a n d useful data. F r o m that p e r s p e c t i v e , Dr. H e r m a n has outlined in this column the basic steps and considerations that need to be addressed in understanding a chart audit. Hopefully, this discussion will assist direct care providers in organizing a n d disseminating the valuable information recorded in client records. In this issue an article e x a m i n i n g the d i a g n o s i s of H I V d e m e n t i a b y R o s e n b e r g a n d c o l l e a g u e s p r o v i d e s an example of h o w the chart audit can be a valuable tool in evaluating patient care and diagnostic procedures.
Certification examination April 5, 1997 Cost ANAC member: $200 Non-ANAC member: $280 The HIV/AIDS Nursing Certification Board (HANCB) is responsible for the development and administration of the Certification Program in HW/AIDS Nursing. It was established by ANAC to develop and administer the certification examination. Certification is a voluntary process through which the HANCB validates an individual RN's qualifications and knowledge in the specialized area of HW/AIDS nursing practice. RNs who complete the Certification Examination in HIV/AIDS Nursing will be entitled to indicate board certification status by using the letters ACRN. Eligibility. Current license as a RN in the United States (or the international equivalent) and at least two years of experience in clinical practice, education, management, or research in HW/AIDS nursing are recommended for eligibility to take the Certification Examination in HIV/AIDS Nursing. To obtain the Certification Examination in HIV/AIDS Nursing Handbook for Candidates and application, complete the form below and mail to: HW/AIDS Nursing Certification Board c/o Professional Testing Corp 1211 Ave. of the Americas/15th floor New York NY 10036 or call/fax: tel: 212/852 --0400 fax: 212/852 -0414 Name: Address: city
72
state
zip
JANAC Vol. 7, No. 6, November-Decembe~ 1996