Not documented, not done. Really?

It is important to find ways to accurately understand what occurs during medical care. Reviews of medical records and patient surveys are commonly used as proxies for actually being inside an exam room and observing the visit.

But before we use these methods to figure out what happens during a patient visit, we first need to make sure that what we measure reflects what actually happened.

Counseling for nutrition and physical activity for children is a quality measure in the Healthcare Effectiveness Data and Information Set, a widely used set of performance measures in the managed care industry. Such counseling also is a criterion for “meaningful use” of electronic health records under the American Recovery and Reinvestment Act

My colleagues and I published a study last month that found the parental report via the use of a questionnaire administered immediately following their child's visit is a more valid method of assessing physician counseling on weight, nutrition and physical activity in primary care, compared to medical record documentation.

We audio-taped about 200 primary care visits and asked parents to fill out a questionnaires right after the visit to ask them what was discussed. We also reviewed electronic health records for these visits. The study suggests that electronic health record documentation may significantly underestimate the counseling that patients receive. What goes into electronic medical records may also vary depending upon nuances in electronic health record tools and templates used by physicians.

- Ulfat Shaikh
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