Validity of the medical record for evaluation of telephone management

The purpose of this study was to determine whether the medical record provides accurate documentation of the telephone encounter. The study was a "blinded" comparison of audiotaped telephone encounters and corresponding medical records; it was carried out in the continuity clinic of a primary care pediatric resident-training program. During their first month of rotation through the outpatient department, 17 PL-I residents received one or two calls made by a "simulated mother" using standardized scripts. Transcripts of these calls and the corresponding written medical records were rated by an examiner unaware of the resident's identity. A standardized instrument was used to measure three aspects of performance: General History Taking, Specific History Taking, and General Management. A percentage of agreement was calculated for each scale, and rating scores of audiotapes and written records were compared. Twenty-seven pairs of audiotape and written documentation were analyzed. The mean percentage of agreement between audiotapes and written records was high: 78% for General History Taking, 78% for General Management, 77% for Specific History Taking. Rating scores of the audiotape and the medical record were significantly correlated for two of the scales: General Management (r = .55, P less than .01) and Specific History Taking (r = .50, P less than .01). Most aspects of the telephone encounter were well documented in the medical record. However, several discrepancies were noted when audiotapes and medical records were compared for the presence of specific items. With the exception of the Specific History Taking scale, there was no correlation between the length of the written record and the percentage of agreement.