Traditional Hospital Records as a Source of Clinical Data in the Outpatient Setting

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Citation: Paul C. Tang and Danielle Fafchamps and Edward H. Shortliffe. (1994) Traditional Hospital Records as a Source of Clinical Data in the Outpatient Setting. In KSL-93-41, November,1994.

Publication techreport ( Edit )
type Technical Report
bibtype techreport
Bibtex basics
author Paul C. Tang and Danielle Fafchamps and Edward H. Shortliffe
title Traditional Hospital Records as a Source of Clinical Data in the Outpatient Setting
number KSL-93-41
institution Knowledge Systems, AI Laboratory
year 1994
month November
Bibtex more
note Updated November 1994.
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abstract Objective: To determine the success with which physicians find patient information using traditional hospital records as the source of data when making clinical decisions in ambulatory care. Further, to characterize the patient information sought by physicians during routine outpatient visits.Design: Observational study.Setting: Internal medicine clinic at a university hospital.Participants: Residents (27), faculty physicians (13), nurses (3), and clerical staff (4).Measurements: We recorded 168 consecutive patient cases presented to attending physicians by internal medicine residents. We analyzed transcripts to identify questions indicating that the physicians could not find patient information in the medical record. We performed thematic analysis to generate a set of prototypical questions asked by physicians regarding patient information.Results: In 136 of 168 (81 percent) cases, physicians could not find all the patient information that they desired during a patient's visit. We documented 538 instances of patient information that could not be drived from the hospital chart, 370 (69 percent) of which involved data generated at the same institution where the patient was being seen. Patient-information queries were grouped into 15 prototypical queries.Conclusions: The multi-authored medical record system we studied did not provide effective access to patient information for physicians making clinical decisions in an outpatient setting. Improved methods for addressing prototypical questions arising in routine practice are needed.

KSL Technical Report ID: KSL-93-41
Facts about Traditional Hospital Records as a Source of Clinical Data in the Outpatient SettingRDF feed
Abstract Objective: To determine the success with … Objective: To determine the success with which physicians find patient information using traditional hospital records as the source of data when making clinical decisions in ambulatory care. Further, to characterize the patient information sought by physicians during routine outpatient visits.Design: Observational study.Setting: Internal medicine clinic at a university hospital.Participants: Residents (27), faculty physicians (13), nurses (3), and clerical staff (4).Measurements: We recorded 168 consecutive patient cases presented to attending physicians by internal medicine residents. We analyzed transcripts to identify questions indicating that the physicians could not find patient information in the medical record. We performed thematic analysis to generate a set of prototypical questions asked by physicians regarding patient information.Results: In 136 of 168 (81 percent) cases, physicians could not find all the patient information that they desired during a patient's visit. We documented 538 instances of patient information that could not be drived from the hospital chart, 370 (69 percent) of which involved data generated at the same institution where the patient was being seen. Patient-information queries were grouped into 15 prototypical queries.Conclusions: The multi-authored medical record system we studied did not provide effective access to patient information for physicians making clinical decisions in an outpatient setting. Improved methods for addressing prototypical questions arising in routine practice are needed. ns arising in routine practice are needed.
Author Paul C. Tang and Danielle Fafchamps and Edward H. Shortliffe  +
Bibtype techreport  +
Has author Paul C. Tang and Danielle Fafchamps and Edward H. Shortliffe  +
Has identifier KSL-93-41  +
Has publishing details November,1994  +
Has title Traditional Hospital Records as a Source of Clinical Data in the Outpatient Setting  +
Has where published KSL-93-41  +
Has year 1994  +
Institution Knowledge Systems, AI Laboratory  +
Ksl tr id KSL-93-41  +
Month November  +
Note Updated November 1994.
Number KSL-93-41  +
Process note NO  +
Title Traditional Hospital Records as a Source of Clinical Data in the Outpatient Setting  +
Year 1994  +
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