Emergency department daily record review: a quality assurance system in a teaching hospital. 1988

F P Harchelroad, and M L Martin, and R M Kremen, and K W Murray
Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212-9986.

A system of daily patient chart review of 11 categories of physician documentation and patient care was implemented over a 36-month period at Allegheny General Hospital in Pittsburgh. A total of 108,317 charts of emergency patients were reviewed. Feedback on errors in all categories were given to the physicians responsible, and necessary corrective actions were taken as soon as possible. All new resident physicians rotated in two-month blocks and received orientation to patient care and chart documentation expectations prior to starting the service. All physicians' charts underwent the same thorough chart review. Not only did the percentage of errors decrease from the first months to the second months of the residents' rotations, but the yearly percentage of total errors decreased as the study progressed, from 5.47% to 3.57%.

UI MeSH Term Description Entries
D008499 Medical Records Recording of pertinent information concerning patient's illness or illnesses. Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D010414 Pennsylvania State bounded on the north by New York and Lake Erie, on the east by Delaware and New Jersey, on the south by Delaware and Maryland, and on the west by Ohio and West Virginia.
D011785 Quality Assurance, Health Care Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Assessment, Health Care,Health Care Quality Assessment,Health Care Quality Assurance,Healthcare Quality Assessment,Healthcare Quality Assurance,Quality Assessment, Healthcare,Quality Assurance, Healthcare,Assessment, Healthcare Quality,Assessments, Healthcare Quality,Assurance, Healthcare Quality,Assurances, Healthcare Quality,Healthcare Quality Assessments,Healthcare Quality Assurances,Quality Assessments, Healthcare,Quality Assurances, Healthcare
D003211 Concurrent Review Review of the medical necessity of hospital or other health facility admissions, upon or within a short time following an admission, and periodic review of services provided during the course of treatment. Continued Stay Review,Review, Concurrent,Review, Continued Stay,Concurrent Reviews,Continued Stay Reviews,Reviews, Concurrent,Reviews, Continued Stay
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D004636 Emergency Service, Hospital Hospital department responsible for the administration and provision of immediate medical or surgical care to the emergency patient. Emergency Outpatient Unit,Emergency Services Utilization,Hospital Emergency Room,Hospital Emergency Service,Hospital Emergency Services Utilization,Accident and Emergency Department,Emergency Departments,Emergency Hospital Service,Emergency Room,Emergency Units,Emergency Ward,Hospital Service Emergency,Service, Hospital Emergency,Department, Emergency,Departments, Emergency,Emergencies, Hospital Service,Emergency Department,Emergency Hospital Services,Emergency Outpatient Units,Emergency Room, Hospital,Emergency Rooms,Emergency Rooms, Hospital,Emergency Services, Hospital,Emergency Unit,Emergency Wards,Emergency, Hospital Service,Hospital Emergency Rooms,Hospital Emergency Services,Hospital Service Emergencies,Hospital Service, Emergency,Hospital Services, Emergency,Outpatient Unit, Emergency,Outpatient Units, Emergency,Room, Emergency,Room, Hospital Emergency,Rooms, Emergency,Rooms, Hospital Emergency,Service Emergencies, Hospital,Service Emergency, Hospital,Service, Emergency Hospital,Services Utilization, Emergency,Services Utilizations, Emergency,Services, Emergency Hospital,Services, Hospital Emergency,Unit, Emergency,Unit, Emergency Outpatient,Units, Emergency,Units, Emergency Outpatient,Utilization, Emergency Services,Ward, Emergency,Wards, Emergency
D005568 Forms and Records Control A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records. Records Control,Forms Control,Records Management,Controls, Records,Management, Records,Records Controls
D006746 Hospital Bed Capacity, 500 and over The number of beds 500 or more which a hospital has been designed and constructed to contain. It may also refer to the number of beds set up and staffed for use. Hospital Bed Capacity 500 Over
D006784 Hospitals, Teaching Hospitals engaged in educational and research programs, as well as providing medical care to the patients. Hospital, Teaching,Teaching Hospital,Teaching Hospitals
D014600 Utilization Review An organized procedure carried out through committees to review admissions, duration of stay, professional services furnished, and to evaluate the medical necessity of those services and promote their most efficient use. Review, Utilization,Reviews, Utilization,Utilization Reviews

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