Cardiologists' charting varied by risk factor, and was often discordant with patient report.
J Clin Epidemiol
; 61(10): 1073-9, 2008 Oct.
Article
em En
| MEDLINE
| ID: mdl-18411042
ABSTRACT
OBJECTIVE:
To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report. STUDY DESIGN ANDSETTING:
A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance.RESULTS:
With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's k, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history.CONCLUSION:
Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.
Texto completo:
1
Base de dados:
MEDLINE
Assunto principal:
Doenças Cardiovasculares
/
Prontuários Médicos
Tipo de estudo:
Clinical_trials
/
Etiology_studies
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Risk_factors_studies
Limite:
Aged
/
Female
/
Humans
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Male
/
Middle aged
País como assunto:
America do norte
Idioma:
En
Ano de publicação:
2008
Tipo de documento:
Article