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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