Article Text

  1. P. Katrapati1,
  2. M. Panda2
  1. 1University of Tennessee, Memphis, TN
  2. 2Medical College of Ohio


Background Medical errors cause 44,000 deaths and lead to enormous cost burden. One of the reasons cited is poor documentation by physicians. Proper documentation is a skill important to physician-in-training. Chart audits are a method of quality assurance for physicians-in-training.

Purpose 1. To compare the documentation skills of the first, second, and third year residents through a chart self-audit process. 2. To determine the accuracy of self-audits compared to third party audits.

Methods A 39-item audit form addressing dictations, medications, and preventive health, based on the HEDIS, was developed. Each resident audited 5 of their own medical charts. All charts were reviewed by 2 blinded independent researchers and these were considered the gold standard. For analysis the audit form was divided into 6 components described in table below.

Results Twenty-seven residents completed 135 audit forms. The table below summarizes the agreement rate (%) between residents and gold standard.

Residents' performance compared to gold standard varies between each component and postgraduate year for variables examined, the PGY-1 seemed to fare better. There were significant differences in accuracy between the resident audits and the gold standard in the areas of preventative health and updated medication list.

Conclusions Self-audits may not be an appropriate tool for monitoring quality of care in a resident outpatient clinic because they are inaccurate; resident experience does not appear to improve performance. Electronic medical records may be more appropriate tools for providing residents with performance feedback.

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