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A retrospective chart audit evaluating the degree of adherence of health-care personnel to guidelines for continuous intravenous infusion of morphine sulfate was conducted. The audit was conducted one year after implementation of guidelines for administering morphine sulfate by continuous i.v. infusion. Audit criteria were developed from these guidelines and used to evaluate justification of use, adherence of physicians, pharmacists, and nurses to procedures, and patient outcome. Audits were completed for 11 of 13 patients who received morphine sulfate infusions during the one-year study period. All patients met the standard for justification of use. Adequate patient outcome, defined as chart-documented pain relief within 24 hours, was achieved in six patients. The median time to pain control was 20 hours (range 4-168 hours). Physicians' and pharmacists' adherence to the guidelines was acceptable in over 80% of patients, but documentation of hourly monitoring of blood pressure and respiratory rate and rhythm by nurses met the standard in only 55% of patients; this may have been related to lack of a designated place in the chart for recording this information. The morphine sulfate infusion guidelines appear to contribute to safe and effective therapy.

The effects of a psychiatric liaison program were studied by a chart audit examination of psychiatric consultations on a medical service. A comparison of the full liaison ward with the other wards revealed significant differences in the use of emergency consultation and psychiatric follow-up treatment. The results indicated improved psychologic management of medical patients on wards with intense liaison involvement but no measurable change in attitude toward the psychiatrist. Evaluation methodology and implications of the results are discussed.

The advent of prospective payment systems prompts nurses to examine cost-related factors in demonstrating savings resulting from quality care. The clinical nurse specialist plays an active role in the examination of variables influencing costs for patients within the specialty. This pilot study utilized a retrospective chart audit of 142 women falling within Diagnostic-related Group 355 (non-radical hysterectomy, age less than 70 years, without comorbid condition or complication) during 1985 to identify demographic, illness/treatment-related, and discharge variables related to charge variance. Independent (length of stay, p less than 0.001 and previous admission, p = 0.066) predictors of charge variance were found among the 14 variables studied. The value of the research as a model for other practitioners is discussed.

This study explored the criterion-related validity of a clinical simulation by examining nurse practitioner's (NP) performance as measured by a chart audit and direct observation of care with performance on a clinical simulation. The clinical problem for all three instruments was the assessment and management of hypertension. Seventeen NPs completed all three instruments. The findings suggest that the chart audit and observation data were significantly correlated, but neither was significantly correlated with the clinical simulation. No evidence of criterion-related validity was noted, although several limitations of the study prohibited a definitive conclusion. Nurse educators are cautioned about using clinical simulations for evaluating student's performance until there is more support for criterion-related validity.

In a prospective chart audit of university hospital medical inpatients, an alcohol-use history was not recorded in 22% of the charts. Alcohol abuse was recorded in 21% of them. A retrospective chart audit of patients previously discharged from the same wards revealed that psychiatric or other substance abuse consultation had been requested for only 21% of patients in whom a clear-cut alcohol abuse history had been obtained and recorded. These data suggest the need for more screening and consultation for alcohol abuse by primary care physicians and more involvement of consultation-liaison psychiatrists in the care of patients with alcohol abuse.

A method of peer review, based on retrospective chart audit and patient care review, is described. This method can help physical therapists fulfill their responsibility of reviewing their services in order to provide optimal care.

The home visit has become a integral part of treatment programs for a large number of patients at the Spaulding Rehabilitation Hospital. It is especially useful for elderly patients, who represent a considerable share of the caseload, and has proven to be most beneficial for those individuals who are returning home to live alone or be alone part of the day. At Spaulding the hyome visit is most often conducted by an occupational and physical therapist team who follow a specific evaluation protocol examining the patient's home environment vis-a-vis anticipated functional status at discharge. Recommendations and suggestions for both use patterns and possible structural changes follow. In order to both evaluate the process and the results of home visits a chart audit was conducted from which various ways have been discovered to improve the value of this treatment activity and thereby enhance a patient's quality of life after discharge.

Criteria were developed by the Joint Committee on Quality Assurance for evaluation of ambulatory child health care through chart audit. These covered history, physical examination, laboratory tests, and management in the areas of health supervision, tonsillopharyngitis, bronchial asthma, and urinary infection. Following testing for self-audit of patient records by practitioners, the criteria were rated for relevance to outcome and suitability for use in peer review by 390 "experts," half academicians and half practitioners. The experts showed marked concordance, substantially agreeing as to relevance in 203 of 211 criteria and in 199 regarding use in peer review. Only three quarters of the criteria were, however, considered relevant to outcome by 85 per cent of the experts. The study suggests that academicians and practitioners will agree well in judging criteria for peer review; however, small groups unaccustomed to the task should not be charged with developing criteria of such importance.

A principal method of studying physician practice patterns has been to examine physicians' responses to brief written cases. We have compared this method with practice patterns of the same physicians derived from chart audit. Subjects were 98 family practice residents for whom data were available in actual patient encounters for the workup of asymptomatic hypertension. Short, carefully structured case reports using four cues were designed and a checklist similar to the one used for test ordering in practice was employed. Chart reviews and billing encounter forms were used for comparison. Results indicated residents ordered fewer tests in clinical practice, due, in part, to practice constraints not represented in the written cases. Physicians tend to make the diagnosis of hypertension incrementally in practice, with no one visit adequately representing the point of diagnosis. Studies based on data bases using a patient encounter as the unit of analysis in chronic disease such as hypertension may spuriously underestimate the actual number of tests ordered for the workup. Judgment cases may better reflect the patterns of use of information in a well-defined problem. Prediction of number of tests ordered in the clinical setting has not been established in this case.

Although considerable gains have been made in hypertension control in the United States, the rate of control in blacks is lower than in whites. It has been asserted that this low control rate in blacks is due to lack of compliance. Using previously tested and new measures, as well as chart audit, this pilot study evaluated the specific role and effectiveness of the black church in promoting compliance with antihypertension regimens. A sample of 63 hypertensive subjects from two inner-city black churches participated; 33 were from a church that had a hypertension screening project and 30 were from one that did not. Clients from the church with the project did not score higher on a self-report compliance measure than those from the church without the project. Furthermore, no relationship was found between support and compliance and blood pressure control, although relationships were seen between age and compliance scores, and between following a doctor's advice and compliance scores. The church without a screening program was viewed by clients as more supportive than the one with the program.

An exploratory study was conducted to gather data regarding patient expectations of, and response to, the use of the Nd: YAG laser for endometrial ablation. The data provided identification of typical occurrences experienced by patients. The study was conducted with 30 patients in four segments including preoperative interview, retrospective chart audit, and two postoperative follow-up questionnaires. Preoperatively, patients were assessed with regard to their understanding of the procedure, symptoms, and questions. Intraoperatively, it was determined that the average anesthesia time was 52 min. The mean average amount of fluid absorbed by patients was 735 cc with a range of 100-2000 cc. The average length of stay in the recovery room was 91 min. All but one patient was discharged the same day. Ten patients responded to the 3-month survey. Nine patients (90%) stated they were satisfied with the results of the surgery. Six patients (60%) stated they were having no menstrual periods, and four indic...

The effect of postpartum sibling visitation on the incidence of bacterial colonization in neonates was investigated in a 32-bed obstetrical unit of a midwestern university hospital. Siblings, following a temperature check, handwashing with a Hibiclens® solution, and the donning of a patient covergown, were allowed unrestricted interaction with the infant. Statistical analysis of discharge cultures of nares and umbilici revealed that there was no significant difference between the control group and the experimental group. There was no difference between the two groups in the chart audit for postnatal infection at the first pediatric visit. Data analysis supported the hypothesis that sibling visitation does not increase bacterial colonization in neonates.

To the Editor.— The article by Popkin et al in theArchives(36:386-389, 1979) raises an important question to those of us who do psychiatric consultations. If our colleagues do not follow our recommendations to a significant degree, how can this be remedied to improve the effectiveness of our consultations? Not only may the psychiatrist be wasting his time in many of these cases, but the patient is deprived of treatment that may improve his condition, and the primary physician is left without a solution to the problem that prompted him to ask for a consultation. In the course of evaluating certain aspects of a liaison-consultation service by chart audit, 1 we found that of 55 recommendations involving psychotropic medications, ten (18.2%) were disregarded. This is consistent with the 24% nonconcordance rate found by Popkin et al. Other types of standard recommendations were also examined. Seven of 24 (29.2%) recommendations for

The authors evaluated the effectiveness of chart audit with written feedback as a tool for encouraging second- and third-year residents to obtain and record occupational information during history-taking. Baseline information was obtained by reviewing the charts of 20 residents of patients who presented for complete history-taking and physical examination and scoring for various aspects of occupational history-taking. Intervention was directed at 10 of the residents; the other 10 served as controls. Between five and 12 charts were reviewed for each of the 10 residents in the intervention group; the scoring sheet, scoring criteria, results, and a brief discussion of potentially relevant occupational concerns for the given patient were returned to the resident, along with copies of the relevant pages of the patient's record. Chart review showed no difference in total scores for occupational history-taking between the two groups before intervention. The postintervention scores improved insignificantly for the intervention group; however, the scores deteriorated significantly for the control group (1.38 to 0.92, .05 greater than p greater than .025).

The UCLA Experimental Medical Care Review Organization (EMCRO), in an attempt to minimize the problem of applying a general list of criteria to each patient with a specific condition, has developed a method called Criteria Mapping. This method uses sequential judgments based on the specific clinical data for the individual patient to assess the quality of care by medical record audit. The method does not penalize the physician for omitting unnecessary procedures by allowing alternate decisions when appropriate, and provides supporting reference materials to allow nonphysicians to make reliable medical interpretations of the data in medical records. It is expected that this method will more accurately reflect the physicians' intentions, and that process, when measured by this approach, may correlate better with the outcome of medical care.

Because asthmatics have the highest utilization rate (11%) kin our emergency department (ED) observation unit (OU), we conducted a study correlating predictors of the need for OU therapy to initial disposition (ID) and final disposition (FD) using chart audit of treated asthmatics. Twenty-four clinical variables. (historical, physiological, laboratory, therapy response) were examined utilizing chi-square and Student's t tests. Forty-six asthmatics were treated during a four-month period in 1980. The ID breakdown was as follows: 1) home, 17; 2) OU, 23; and 3) admit, 6. Twenty-seven (59%) of the patients received treatment in the OU at some point in their attack (initial or rebound); 18 (39%) were definitively treated in the ED, and nine (20%) were admitted. The mean OU stay was 19 hours at a cost that was 34% of that incurred for a hospital admission. The FD differed from the ID in 14 of 46 (30%): 1) home, 12; 2) holding, observation, and short-term therapy, 18; and 3) admit, 16. Clinical variables correlating significantly with definitive therapy based on ID and FD were historical; symptoms greater than 24 hours, prior OU admissions, and prior hospitalizations. We conclude that the OU is appropriate, safe, and less expensive than admission; is not used for procrastination in decision making and decreases the hospitalization rate. Historical data correlated significantly with both ID and FD, while clinical variables were of little predictive value.

Using retrospective chart audit (RCA) to identify educational needs, Patient Care Related Reading (PCRR), a hospital-based continuing education program for nurses was developed. The study determined that, used alone, RCA was an inadequate tool for developing continuing education. First, deficiencies in patient care identified through RCA were frequently attributed to administrative rather than educational factors. Second, the audit process itself was unreliable due to inaccurate and delayed documentation (procedures) as well as a narrow focus. Thus, educational needs identified solely through RCA were frequently outdated, limited in scope, and not always relevant to current educational program planning. To best reflect current nursing care practices as well as administrative and staff interests, the RCA should be combined with other approaches to identify educational needs.

• General pediatricians provide comprehensive care for many children with insulin-dependent diabetes mellitus. To assess and improve our ambulatory training program, we first evaluated diabetes-specific care behaviors by residents in their continuity clinics and then introduced a structured visit encounter form. Based on established guidelines provided to the residents, a chart audit indicated appropriate measurement of glycosylated hemoglobin 40% of the time, cholesterol 90% of the time, urine protein 50% of the time, and thyroxine 66.7% of the time. Height was plotted 23% of the time, blood pressure was noted 66% of the time, and ophthalmologic referrals were documented 60% of the time. Requests for assistance from nonphysician members of a multidisciplinary diabetes team were minimal. After introduction of the structured visit encounter form, care behaviors did not improve. New training approaches to prepare general pediatric residents to provide excellent diabetes care are needed. ( AJDC . 1989;143:1173-1176)

The aim of this study was to identify factors in primary care physicians' decisions to refer obese patients to an endocrine clinic. Charts of 83 referred obese patients were compared with randomly selected charts of 300 obese adults in the general ambula tory clinic files. The referral rate is estimated at 1% of obese patients in the clinical center and 0.25% of obese persons in the Lansing area. Referral of obese patients appears to depend primarily on degree of obesity and secondarily on suspicion of endocrine disease. Considerations limiting the usefulness of patient charts for studies of physicians' decision making are discussed. (Med Decis Making 3:69-79, 1983)

Context When examining wait times for specialist care, the duration between a patient's referral and specialist visit (wait time one) is poorly understood. Objectives To calculate wait time one in primary care clinics across Ontario using chart audit. Methods We conducted a retrospective chart audit at five Ontario-based primary care clinics in 2014-2015. Results We analyzed 461 referrals. Median wait time one for non-urgent and urgent referrals was 79 and 49 days, respectively. Gastroenterology, obstetrics/gynecology, and ear, nose and throat received the most referrals. Wait times were longest for dermatology (112 days) and shortest for general surgery (32 days). Conclusion Wait times vary substantially by referral urgency and specialty type in Ontario. Calculating wait time from primary care clinics directly offers new perspectives on wait time one and enables clinics to target improvement efforts to best meet patient needs. Our findings will be relevant to providers and policy makers interested in implementing strategies to reduce wait times.

Methods: We used national administrative data and a chart audit in a retrospective cohort design. We identified discharge diagnoses of stroke in the 10 Canadian provinces between 2008 and 2009. We drew a sample (over-weighted by population and hospital size) for a detailed chart review that was focused on identifying indicators of acute stroke care. We determined the proportions of thrombolysis use, complications and outcomes, adjusted for age and sex and stratified by type of hospital. Results: Our final audit sample included 9588 patient charts, representative of 88% of the 43 651 cases of stroke for which patients were admitted to hospital in Canada. A total of 5.4% (95% confidence interval [CI] 5.1–5.6) of patients with stroke and 6.1% (95% CI 5.8–6.4) of patients with ischemic stroke received thrombolysis. Comprehensive stroke centres used thrombolysis in about one-third of ischemic cases — double the rate seen in primary stroke centres. Often (35%–49% of the time), thrombolysis was not given owing to an interval of more than 4.5 hours between stroke onset and arrival at hospital. Interpretation: The use of thrombolysis for acute stroke in Canada remains low and is limited by delays in both the arrival of patients to hospital and the in-hospital processes of neuroimaging and thrombolysis administration. Our data show the critical need for concerted national efforts to improve education regarding the treatment of acute stroke and speed up stroke management in the hospital setting.

The problem-oriented medical record (POMR) is designed to rationalize and improve the structure of the medical record. This change might be expected to enhance the outcome of patient care. Therefore, I assessed the effect of the POMR on the care of the problem— anemia—in a Veterans Administration teaching hospital. The POMR concept was introduced by lectures and supported by chart audit. Four months later, the care described in 29 sequential records containing the discharge diagnosis—anemia—was compared with 31 records produced at the same period in the previous year by house officers not using the POMR. Records were graded for maintenance of the POMR format. Completeness of the "data base," as well as time to problem identification, therapy, and diagnostic description were compared. Introduction of the POMR had no observable beneficial effect on the thoroughness of data base accumulation or the process of patient care for the problem (anemia) or, in another study, on the ease or accuracy of chart audit. ( Arch Intern Med 136:1119-1123, 1976)

Outpatient chart audit, as performed by Russo et al.'s faculty,1 demonstrates the problems of measurement as much as that which is measured. By now, with national emphasis on inpatient audit,2 it is evident that medical education and practice have neglected documentation of care given–this despite a long-time need for accurate, concise, legible record-keeping to assist in care by multiple professionals, to support disability evaluations, to avoid malpractice claims, to effect third-party reimbursement, and to enhance clinical investigation, among others.

Workups by physicians in response to five common complaints in a sample of 104 men and women—52 married couples—were evaluated by chart audit. For the total group of complaints, back pain, headache, dizziness, chest pain, and fatigue, the physicians' workups were significantly more extensive for men than they were for women. These data tend to support the argument that male physicians take medical illness more seriously in men than in women. ( JAMA 241:2186-2187, 1979)

To the Editor.— The rigorous research design and careful data collection and interpretation used by Pinkerton et al (1980;244:2183) admirably replicate previous reports that mere transmission of information in episodic learning rarely changes clinical behavior. 1 Their interpretations, however, do not fully explore the medical education issues they address. The authors describe an educational intervention as consisting only of a videotape. In fact, the full learning activity included at least six steps: (1) chart audit to identify learning need, (2) transmission of relevant information via videotape, (3) pretesting and post-testing to assess gain of factual information, (4) further chart audit to see if information gained was being translated into clinical performance, (5) feedback to learners when chart audit showed no adoption of the fluoridation protocol, and (6) personal supervision of each resident. The result was a successful learning experience: "90.7% of pediatric patients assigned to these residents were ingesting the

In this issue of theArchives, Hansen and associates 1 present data from a chart audit reflecting physician behavior in the interpretation of RBC indexes. The authors begin with the fact that patients having low mean RBC volumes and high RBC counts relative to those volumes will commonly be found to have thalassemic syndromes if properly examined. Physicians working in areas with large populations of patients from racial stock originating in the Mediterranean basin and large populations of black patients have had to concern themselves with this problem for years. Now the influx of refugees from Southeast Asia increases the numbers of persons at risk and distributes the problem to new regions of this country. Additionally, the need for cost control in medical care increases the incentive to make appropriate clinical decisions based on relatively inexpensive tests such as RBC indexes. Since RBC indexes are routinely provided as part of

Background About 55% of the population 40 to 80 years of age in Barbados is hypertensive. The quality of hypertension primary care compared to available practice guidelines is uncertain. Findings Charts of hypertensive and diabetic patients were randomly sampled at all public and 20 private sector primary care clinics. Charts of all hypertensive patients ≥ 40 years of age were then selected and processes of care and blood pressure (BP) maintenance < 140/90 documented. 343 charts of hypertensive patients (170 public, and 173 private) were audited. Patients had the following characteristics: mean age 64 years, female gender 63%, mean duration of diagnosis 9.1 years, and diabetes diagnosed 58%. Patients had an average of 4.7 clinic visits per year, 70% were prescribed a thiazide diuretic, 42% a calcium channel blocker, 40% an angiotensin receptor blocker, and 19% a beta blocker. Public patients compared to private patients were more likely to be female (73% vs. 52%, p < 0.01); have a longer duration of diagnosis (11.7 vs. 6.5 years, p < 0.01), and more clinic visits per year (5.0 vs. 4.5, p < 0.01). Over a 2 year period, the proportion of charts with the following recorded at least once was: BP 98%, weight 80%, total cholesterol 71%, urine tested for albumin 67%, serum creatinine 59%, dietary advice 55%, lipid profile 48%, exercise advice 45%, fasting blood glucose for non-diabetics 39%, dietician referral 21%, tobacco advice 17%, retinal examination 16%, body mass index 1%, and waist circumference 0%. Public patients were more likely to have recorded: weight (92% vs. 68%, p = < 0.01); tests for total cholesterol (77% vs. 67%, p = 0.04), albuminuria (77% vs. 58%, p = < 0.01), serum creatinine (75% vs. 43%, p < 0.01), and fasting blood glucose for non-diabetics (49% vs. 30%, p = 0.02); dietician referral (34% vs. 9%, p < 0.01), and tobacco advice (24% vs. 10%, p < 0.01). Most (92%) diastolic BP readings ended in 0 or 5 (72% ended in 0). At the last visit 36% of patients had a BP < 140/90 mmHg. Conclusions Improvements are needed in following guidelines for basic interventions such as body mass assessment, accurate BP measurement, use of thiazide diuretics and lifestyle advice. BP control is inadequate.