Traditional medical records as a source of clinical data in the outpatient setting.

Abstract

We conducted an observational study at a university hospital clinic to determine the success with which physicians find patient information using traditional hospital records as the source of data. We recorded 168 consecutive patient cases presented to attending physicians by internal medicine residents, and analyzed the transcripts to identify questions indicating that the physicians could not find patient information in the medical record. In 81 percent of the cases, physicians could not find all the patient information that they desired during a patient's visit. We performed thematic analysis to generate a set of 15 prototypical questions asked by physicians regarding patient information. The multiauthored 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.