A positive, systematic approach to improve inpatient medical record completion in a family practice residency program. 1996

D T Purdom, and R S Griffith, and D L Weaver
Department of Community and Family Medicine, University of Missouri-Kansas City, USA.

OBJECTIVE Timely completion of medical records is a concern for many reasons. For physicians, incomplete records may result in loss of hospital privileges and income and increased legal liability after entering practice. Traditionally, medical record delinquencies have been dealt with punitively. We developed a multifaceted approach to inpatient medical record completion and implemented it at our hospital. METHODS The intervention involved posting weekly lists of physicians who were in compliance or noncompliance with medical records completion requirements, giving positive rewards (candy bars) for those who were in compliance, and increasing faculty contact with residents over issues of medical records completion. RESULTS This approach reversed an increasing hospital record delinquency rate that had exceeded 50% and reduced the rate to 10%-30%. Residents' views of the various components of the intervention were positive. CONCLUSIONS Medical records completion rates can be increased with positive, rather than punitive, measures.

UI MeSH Term Description Entries
D007396 Internship and Residency Programs of EDUCATION, MEDICAL, GRADUATE training to meet the requirements established by accrediting authorities. House Staff,Internship, Dental,Residency, Dental,Residency, Medical,Dental Internship,Dental Internships,Dental Residencies,Dental Residency,Internship,Internship, Medical,Internships, Dental,Medical Residencies,Medical Residency,Residencies, Dental,Residencies, Medical,Residency,Residency and Internship,Internships, Medical,Medical Internship,Medical Internships,Residencies,Staff, House
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
D010821 Physicians, Family Those physicians who have completed the education requirements specified by the American Academy of Family Physicians. Family Physician,Family Physicians,Physician, Family
D011678 Punishment The application of an unpleasant stimulus or penalty for the purpose of eliminating or correcting undesirable behavior. Punishments
D003625 Data Collection Systematic gathering of data for a particular purpose from various sources, including questionnaires, interviews, observation, existing records, and electronic devices. The process is usually preliminary to statistical analysis of the data. Data Collection Methods,Dual Data Collection,Collection Method, Data,Collection Methods, Data,Collection, Data,Collection, Dual Data,Data Collection Method,Method, Data Collection,Methods, Data Collection
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D012201 Reward An object or a situation that can serve to reinforce a response, to satisfy a motive, or to afford pleasure. Rewards

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