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Medical
Medical record-keeping and record-keeping
patient perception of hospital
care quality
Van Mô Dang 531
Department of Medicine, Division of Geriatrics, Grenoble University Hospital,
Received 2 February 2013
Grenoble, France, and Revised 4 February 2014
Patrice Franc¸ois, Pierre Batailler, Arnaud Seigneurin, Accepted 23 March 2014

Jean-Philippe Vittoz, Elodie Sellier and José Labarère

Quality of Care Unit, Grenoble University Hospital, Grenoble, France

Abstract
Purpose – Medical record represents the main information support used by healthcare providers. The
purpose of this paper is to examine whether patient perception of hospital care quality related to
compliance with medical-record keeping.
Design/methodology/approach – The authors merged the original data collected as part of a
nationwide audit of medical records with overall and subscale perception scores (range 0-100, with
higher scores denoting better rating) computed for 191 respondents to a cross-sectional survey of
patients discharged from a university hospital.
Findings – The median overall patient perception score was 77 (25th-75th percentiles, 68-87) and
differed according to the presence of discharge summary completed within eight days of discharge
(81 v. 75, p ¼ 0.03 after adjusting for baseline patient and hospital stay characteristics). No independent
associations were found between patient perception scores and the documentation of pain assessment
and nutritional disorder screening. Yet, medical record-keeping quality was independently associated
with higher patient perception scores for the nurses’ interpersonal and technical skills component.
Research limitations/implications – First, this was a single-center study conducted in a large
full-teaching hospital and the findings may not apply to other facilities. Second, the analysis might be
underpowered to detect small but clinically significant differences in patient perception scores
according to compliance with recording standards. Third, the authors could not investigate whether
electronic medical record contributed to better compliance with recording standards and eventually
higher patient perception scores.
Practical implications – Because of the potential consequences of poor recording for patient
safety, further efforts are warranted to improve the accuracy and completeness of documentation in
medical records.
Originality/value – A modest relationship exists between the quality of medical-record keeping and
patient perception of hospital care.
Keywords Patient satisfaction, Documentation, Hospitals, Medical records, Quality standards
Paper type Research paper

Introduction
Although medical records serve many functions, their primary purpose is to record
information about patients and their care (Huston, 2004; Mann and Williams, 2003).
Medical records provide clinical staff caring for patients with information needed to
deliver optimal care in present or future hospital episodes (Carpenter et al., 2007). International Journal of Health Care
Medical-record structure and content have attracted interest for decades (Siegler, 2010). Quality Assurance
Vol. 27 No. 6, 2014
Yet medical record-keeping quality is highly variable (Daucourt and Michel, 2003; pp. 531-543
r Emerald Group Publishing Limited
Mann and Williams, 2003; Osborn et al., 2005). Medical record and communication 0952-6862
standards have been developed in North America and Europe (Royal College of DOI 10.1108/IJHCQA-06-2013-0072
IJHCQA Physicians, 2008a, b; Wood, 2001). Adopting such standards has benefits including
27,6 completeness and accuracy (Mann and Williams, 2003; Martin, 1992), better
communication between clinical care providers (Mann and Williams, 2003) and
decreased adverse events (Zegers et al., 2011). Few studies report a link between
sub-optimal medical records, care processes and clinical outcomes for patients with
specific conditions (Dunlay et al., 2008) and none investigate the potential association
532 between medical-record keeping and patients’ hospital care perceptions. This study
aimed to determine whether patient perceptions are related to medical-record quality.
Specifically, we hypothesized that higher compliance with medical record-keeping
standards were observed for patients reporting higher perception scores. If such an
association is found then patient satisfaction with care might be an incentive for
improving medical records.

Methods
Study design
We merged original data from a nationwide medical-record audit with responses to
a cross-sectional university hospital patient survey. Individual-level compliance with
medical-record standards were linked to respondent perception scores via hospital
identifiers. Because the two studies were designed and conducted independently, fewer
patients appeared in both samples. To increase our sample size, we elected to audit
additional medical records, which were randomly selected among the cross-sectional
survey respondents.

Study site
Grenoble University Hospital is a full-teaching hospital with 1,347 acute-care beds
serving a predominantly urban population (450,000). It also serves as the regional
referral centre for the French Northern Alps. Hospital data show 58,412 acute-care
stays, with a 6.7 days mean stay in 2010.

Patient hospital care quality perception

In total, 1,500 patients discharged consecutively from acute-care departments were
selected in April 2010 (Batailler et al., 2014). Medical, surgical or obstetrics and
gynecology inpatients staying more than one day were eligible if they were discharged
alive to home or to a nursing home. Patients transferred to other acute care hospitals
and those discharged to post-acute care facilities were not eligible. There was no
diagnostic limitation to patient selection. The patients’ care quality perceptions were
collected using a standardized survey instrument (Labarere et al., 2001), which
included 29 items covering six key hospital care quality components: physician and
nurse interpersonal and technical skills, information, continuity, convenience
and living arrangements (Appendix 1). Each item was rated on a four-point Likert
scale ranging from strongly disagree (1) to strongly agree (4). The survey instrument
also included an overall satisfaction item and two items dealing with patient’s intent
to recommend the hospital and to return to the hospital for care. The questionnaire was
mailed to patients within two to four weeks of discharge along with a pre-paid
envelope, a letter guaranteeing patient confidentiality and encouraging participation.
A follow-up letter was sent to non-respondents two weeks later. For each patient,
we computed six subscale scores, each corresponding to a hospital care quality
component and an overall score based on his/her 29 item ratings. Each subscale score
was computed as the mean of the individual items constituting the corresponding
component. Subscale and overall scores ranged between 0 and 100; higher scores Medical
denoting better ratings. Subscale scores were coded as missing if more than half the record-keeping
corresponding items had omitted values. Questionnaires with more than six missing
values (i.e. an overall proportion higher than 20 percent) were excluded from the
analysis; the same strategy used in the original survey instrument’s development
and validation (Labarere et al., 2004).
533
Medical-record audit
The French agency for healthcare quality (Haute autorité de santé) requires hospital
staff to audit medical record and discharge summary structure and content annually
(Couralet et al., 2013). In 2010, 354 patients with stays longer than one day were
randomly selected among the computerized discharge summaries recorded in our
hospital administrative database. In total, 80 hospital stays were sampled to comply
with the national audit requirements and 274 additional hospital stays were appraised
for local convenience. We examined electronic and paper medical records and collected
data using a centralized password-secured web site. The audit tool and help notes
had been developed, pre-tested and assessed for inter-rater reliability during a
pilot study (Corriol et al., 2008). The tool comprised 75 items and assessed overall
medical-record keeping, pain assessment, nutritional disorder screening and discharge
summary timeliness and completeness (Appendix 2). The overall medical-record
score comprised ten items while the three other standards were binary. Because each
standard yielded specific exclusion criteria, audited medical-record numbers varied
across standards.

Statistical analysis
Categorical variables were reported as numbers and percentages, and continuous
variables as median, 25th and 75th percentiles. In univariable analysis, differences in
overall medical record-keeping score according to patient and hospital stay
characteristics were compared using the non-parametric Kruskal-Wallis test. Pain
assessment, nutritional disorder screening and timely discharge summary, according
to patient and hospital stay characteristics, were analyzed using the w2 or Fisher exact
test. We performed multivariable quantile regression analysis (Austin et al., 2005) to
examine the independent associations between median patient perception scores
and compliance with standards for overall medical-record keeping, pain assessment
documentation, nutritional disorder screening documentation and discharge summary
timeliness and completeness, respectively. To account for potential confounding by
patient and hospital stay characteristics, the models were adjusted for age, gender,
surgical procedure and length of stay (LoS). Patients enrolled in the two original
studies determined the sample size and no a priori sample size calculation could be
performed for this analysis. Two-tailed p-values o0.05 were considered statistically
significant. All analyses were performed using Stata version 11.0 (Stata Corporation,
College Station, TX, USA). This survey received the French Data Protection Agency’s
(commission nationale de l’informatique et des libertés, Paris, France) approval.

Results
Overall, 870 of the 1,500 surveyed patients returned a questionnaire, yielding a 58
percent participation rate. Data collected from the medical record-keeping audit
were available for 204 respondents. After excluding nine medical records and four
survey questionnaires owing to exclusion criteria, the final sample was 191 patients.
IJHCQA The median age for all patients was 58 years, 95 (49.7 percent) were female and 28 (14.7
27,6 percent) underwent a surgical procedure (Table I).
The medical records included electronic and paper documentation for 154 patients
(80.6 percent), and paper documents only for 37 patients (19.4 percent). The median
overall medical-record quality score was 80/100, with standards compliance ranging
from 46.7 percent for discharge medication order to 100 percent for delivery notes
534 (Table II). Pain assessment and nutritional disorder screening documentation
prevalence was 55.0 and 74.1 percent, respectively. A discharge summary was found
in 117 (61.3 percent) medical records and was completed within eight days following
discharge in 72 records (37.7 percent).
Compliance with recording standards varied according to age and gender (overall
medical-record quality score), surgical procedure (timely discharge summary
completion, pain assessment and nutritional disorder screening documentation) and
LoS (overall medical record-keeping quality score, timely discharge summary
completion and pain assessment documentation) (Table III).

Characteristics N ¼ 191

Age, ya 58 (42-73)
Female gender, n (%) 95 (49.7)
Education level lower than high school, n (%)b 43 (22.5)
Admission to an emergency department observation unit, n (%) 71 (37.2)
Admission to the maternity ward, n (%) 8 (4.2)
Transfer to an intensive care unit within two days of admission, n (%) 10 (5.2)
Surgical procedure, n (%) 28 (14.7)
Discharge to another hospital, n (%) 2 (1.0)
Length of stay, da 5 (4-9)
Table I.
Patient and hospital Notes: aData are given as median (25th-75th percentiles). bValues were missing for education
characteristics level (n ¼ 12)

Standards N ¼ 191

Overall medical record-keeping score, median (25th-75th percentiles)a 80 (60-88)

1. Presence of hospital admission entry (clerking), n (%) 178 (93.2)
2. Complete hospital admission entry (clerking), n (%) 149 (78.0)
3. Complete medication orders, n (%) 138/190 (72.6)
4. Presence of surgical or invasive procedure notes, n (%) 38/40 (95.0)
5. Presence of delivery notes, n (%) 6/6 (100.0)
6. Complete anesthetic record, n (%) 31/41 (75.6)
7. Complete blood transfusion record, n (%) 11/12 (91.7)
8. Complete discharge medication order, n (%) 79/169 (46.7)
9. Complete discharge summary, n (%) 117 (61.3)
10. Medical record structured and organized, n (%) 173 (90.6)
Pain assessment documentation, n (%) 105 (55.0)
Nutritional disorder screening documentation, n (%) 66/89 (74.1)
Timely discharge summary completion, n (%) 72 (37.7)
Table II.
Compliance with medical Note: aThe medical record-keeping score was computed based on compliance with ten standards and
record-keeping standards ranged between 0 and 100, with higher scores denoting better compliance (see Methods)
 Overall medical
record-keeping Pain assessment Nutritional disorder screening Timely discharge summary
Characteristics scorea p documentation, n (%) p documentation, n (%) p completion, n (%) p

Age, y 0.04 0.09 0.45 0.58

o45 67 (60-88) 24/53 (45.2) 16/19 (84.2) 17/53 (32.1)
45-64 73 (50-86) 31/60 (51.7) 23/34 (67.6) 23/60 (38.3)
X65 83 (67-100) 50/78 (64.1) 27/36 (75.0) 32/78 (41.0)
Gender o0.001 0.22 0.20 0.40
Female 67 (50-83) 48/95 (50.5) 30/44 (68.2) 33/95 (34.7)
Male 83 (67-100) 57/96 (59.4) 36/45 (80.0) 39/96 (40.6)
Education level 0.17 0.12 0.21 0.18
Lower than high
school 83 (67-100) 28/44 (63.6) 16/25 (64.0) 21/44 (47.7)
High school or
higher 75 (60-88) 68/135 (50.4) 47/61 (77.0) 49/135 (36.3)
Surgical
procedure 0.25 o0.001 0.02 0.02
No 80 (60-100) 81/163 (49.7) 47/69 (68.1) 56/163 (34.4)
Yes 83 (75-88) 24/28 (85.7) 19/20 (95.0) 16/28 (57.1)
Length of stay, d o0.001 o0.001 0.13 0.02
p3 67 (57-88) 19/47 (40.4) 9/11 (81.8) 13/47 (27.7)
4-5 67 (50-83) 19/55 (34.5) 20/33 (60.6) 15/55 (27.3)
6-9 83 (67-87) 28/44 (63.6) 20/26 (76.9) 23/44 (52.3)
49 86 (80-100) 39/45 (86.7) 17/19 (89.5) 21/45 (46.7)
Note: aValues are given as median (25th-75th percentiles)

baseline characteristics
Medical

according to patient
Medical record-keeping
Table III.
535
record-keeping
IJHCQA The median overall patient perception score was 77 (Table IV), with median subscale
27,6 scores ranging from 75 for the information and physician interpersonal and technical
skills components to 83 for the care continuity component (Table V).
In multivariable analysis adjusting for patient and hospital stay characteristics,
timely discharge summary was the only medical record-keeping standard
associated with higher overall patient perception score (Table IV). No subscale
536 patient perception score differed according to medical record-keeping standards,
excepting nurses’ interpersonal and technical skills score, which was related to overall
medical record-keeping score (Table V). Although pain assessment documentation
was associated with a higher patient-percentage very or fairly satisfied with pain
control (96.8 (92/95) v. 84.1 percent (58/69), p ¼ 0.004), this difference did not remain
significant after adjusting for covariates.
Overall, 172 patients (90.0 percent) were very or fairly satisfied with hospital care.
Higher overall medical record-keeping scores were observed in very or fairly satisfied
patients (median, 81 (60-88) v. 67 (60-67), p ¼ 0.04). Regarding behavioral intentions,
161 patients (84.3 percent) reported that they would likely or very likely recommend
the hospital and return to the hospital for care, with no differences according to
compliance with recording standards.

Discussion
We found limited evidence supporting a potential relationship between patient hospital
care perception and compliance with medical record-keeping standards. Overall,
perceptions related only to the discharge summary timeliness and completeness. No
independent associations were observed between patient perception components and
compliance with recording standards other than a link between overall medical-record
keeping and nurses’ interpersonal and technical skills.
Consistent with prior research, we identified low overall medical record-keeping
quality (Gabbay and Layton, 1992; Mann and Williams, 2003), pain assessment and
nutritional disorder screening (Gabbay and Layton, 1992) and discharge summary
completion (Hansen et al., 2011). Because the medical record represents the main

Standards Overall perception of hospital care quality scorea pb

All patients 77 (68-87) –

Overall medical record-keeping score 0.86
p80 76 (64-84)
480 79 (71-90)
Pain assessment documentation 0.73
No 77 (65-83)
Yes 78 (70-91)
Nutritional disorder screening documentation 0.80
No 80 (73-86)
Yes 79 (68-91)
Timely discharge summary completion 0.03
No 75 (64-84)
Table IV. Yes 81 (73-90)
Overall patient hospital
care quality perception Notes: aData are given as median (25th-75th percentiles). Patient perception scores range between 0
score according to and 100, with higher scores denoting better rating. bp-values were adjusted for age, gender, surgical
medical-record keeping procedure, and length of stay
Standards Perception of hospital care quality scorea

Nurses’ interpersonal and

technical skills pb Information pb Continuity of care pb
All patients 81 (67-95) – 75 (58-92) – 83 (67-92) –
Overall medical record-keeping score 0.04 0.70 0.26
p80 78 (67-93) 75 (50-92) 75 (58-92)
480 86 (74-95) 75 (67-92) 83 (67-92)
Pain assessment documentation 0.23 0.38 0.14
No 77 (67-93) 67 (55-92) 75 (58-92)
Yes 86 (71-95) 75 (67-92) 83 (67-92)
Nutritional disorder screening documentation 0.95 0.21 0.80
No 86 (71-95) 83 (67-92) 76 (67-92)
Yes 86 (67-95) 75 (67-92) 83 (67-92)
Timely discharge summary completion 0.23 0.36 0.16
No 78 (62-93) 67 (50-92) 75 (58-92)
Yes 86 (76-95) 75 (67-92) 83 (67-92)
Physicians’ interpersonal and Living
technical skills pb arrangements pb Convenience pb
All patients 75 (67-92) – 78 (67-89) – 78 (67-89) –
Overall medical record-keeping score 0.78 0.21 0.08
p80 75 (58-92) 78 (61-89) 67 (58-83)
480 75 (67-92) 83 (67-94) 75 (67-89)
Pain assessment documentation 0.50 0.37 0.18
No 71 (58-92) 78 (61-89) 75 (67-83)
Yes 75 (67-92) 83 (67-92) 75 (62-89)
Nutritional disorder screening documentation 0.54 0.06 0.37
No 92 (67-92) 78 (67-94) 75 (67-92)
Yes 75 (58-92) 83 (72-94) 75 (58-89)
Timely discharge summary completion 0.54 0.05 0.36
No 75 (58-92) 78 (61-89) 67 (58-83)
Yes 83 (67-92) 83 (67-94) 75 (67-89)
Notes: aData are given as median (25th-75th percentiles). Patient perception scores ranged between 0 and 100, with higher scores denoting better rating.
b
p-values were adjusted for age, gender, surgical procedure and length of stay
Medical

scores according to
care quality perception
Subscale patient hospital
Table V.

medical–record keeping
537
record-keeping
IJHCQA information for healthcare providers, these findings imply potentially harmful
27,6 consequences for patient safety. Accordingly, higher adverse event rates are associated
with poor information recorded in medical charts (Zegers et al., 2011).
Although speculative, a potential explanation for the association between
medical-record keeping and nurses’ skills scores is that the nurses who document
hospital records more thoroughly may also have better interpersonal skills, leading to
538 higher patient perception. Indeed, patient information recorded in hospital chart likely
reflects the interaction between healthcare providers and the patient (Solomon et al., 2000).
Yet, this hypothesis is partly contradicted by our failure to show a similar
association involving physician interpersonal and technical skills. It is also possible
that medical-record keeping and nurses’ interpersonal and technical skills have
a common origin in safety culture and work environment. On one hand, medical
record-keeping quality is part of the hospital work environment besides other aspects
like physician-nurse relations, nurse participation in decision making and
organizational priorities on care quality. On the other hand, consistent associations
between patient hospital care ratings, nurse work environment and safety culture have
been reported across western countries (Aiken et al., 2012). In this context, that patients
with higher overall medical record-keeping scores were more likely to be satisfied
with their hospital stay was expected, since nursing care perceptions strongly
influences patient satisfaction (Leiter et al., 1998). Interestingly, an independent
association was found between overall patient hospital-care perception and discharge
summaries completed within eight days post discharge. This finding accords with
studies reporting that deficits in information transfer between hospital-based and
primary care physicians at discharge have the potential to negatively affect continuity
and safety (Kripalani et al., 2007).
The weak association between patient perception and pain assessment
documentation was unexpected. Presumably, patients with documented pain
assessment would report higher perception scores for nurse interpersonal and
technical skills, since this subscale comprised an individual item relating to pain
control. However, no independent association was observed between pain assessment
documentation and patient-reported pain control in our study. This observation may
mirror a gap between objectively documented pain assessment and patient satisfaction
with pain control. Although its determinants are not fully understood, patient
satisfaction stems from the discrepancy between patient expectations and perceived
experience, which may differ from actual experience. Patient-reported pain
management procedures is associated with pain relief (Bovier et al., 2004) but
complex relationships exist between patient satisfaction with pain management
and objective pain level measures, delayed analgesia and pain relief (Hanna et al., 2012;
Kelly, 2000).
There are several potential explanations for the modest relationship between
compliance with medical record-keeping standards and patient hospital care quality
perceptions. First, our data represent medical record documentation rather than
observing care directly. Substantial disagreement has been previously demonstrated
between medical record and direct observation, with the potential for chart abstraction
underestimating care quality (Chisholm et al., 2008; Luck et al., 2000; Stange et al.,
1998). Conversely, adequate care may be documented in medical records despite
providing inadequate care, in an attempt to comply with regulatory standards
(Hansen et al., 2011). Second, only modest associations exist between technical care and
patient experience (Jha et al., 2008; Sack et al., 2011). Indeed, patients may rely on
peripheral elements such as comfort, emotional support and friendliness because Medical
they do not feel competent to evaluate technical skills (Luxford, 2012). Third, we record-keeping
cannot say that our survey instrument was valid (Batailler et al., 2014), although this
was unlikely. We used a self-administered French-language questionnaire developed
according to psychometric theory that demonstrated satisfactory validity and reliability
(Labarere et al., 2001).
Our study has limitations; first this was a single-centre study conducted in a large 539
teaching hospital and the findings may not apply to other facilities. Second, the sample
size was determined by patients enrolled in the satisfaction survey and the
medical-record audit. Hence, our analysis might be underpowered to detect small but
clinically significant differences in patient perception scores according to compliance
with recording standards. Third, a recent study reported a positive association
between hospital electronic health records and patient satisfaction (Kazley et al., 2012).
Because the medical records were hybrid, including electronic and paper documents for
most patients enrolled in our study (80.6 percent), we could not investigate whether
electronic medical records contribute to better compliance with recording standards
and eventually higher patient scores. However, computerized documentation also has
specific drawbacks, including unintended copying and pasting.

Conclusions
We found only weak associations between compliance with medical-record keeping
and patient care quality perceptions. It remains unclear whether these findings result
from a failure to provide or to document adequate care. Because poor recording has
consequences for patient safety, further efforts are warranted to improve medical-
record accuracy and completeness.

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Corresponding author
Dr José Labarère can be contacted at: JLabarere@chu-grenoble.fr

(The Appendix follows overleaf.)

IJHCQA Appendix 1
27,6
Perception of hospital care quality scores and items N ¼ 191

I. Nurses’ interpersonal and technical skillsa 81 (67-95)

1. Nurses’ availability, n (%)b 168 (89.8)
542 2. Nurses’ courtesy, n (%)b 181 (95.3)
3. Prompt response to call button, n (%)b 142 (81.6)
4. Pain control, n (%)b 150 (91.5)
5. Nurses’ technical skills, n (%)b 180 (95.7)
6. Nurses’ interest in patient’s worries and needs, n (%)b 173 (92.0)
7. Waiting time following admission, n (%)b 169 (88.9)
II. Informationa 75 (58-92)
8. Information about side effects of medications, n (%)b 141 (81.5)
9. Information about purpose of tests or treatments, n (%)b 162 (87.6)
10. Communication of tests results, n (%)b 137 (76.1)
11. Provision of information in an understandable way, n (%)b 155 (87.1)
III. Continuity of carea 83 (67-92)
12. Information on recovery process, n (%)b 119 (76.3)
13. Instructions about medical follow-up, n (%)b 149 (87.6)
14. Efficiency of the discharge procedure, n (%)b 168 (91.3)
15. Provision of information to family members, n (%)b 134 (80.2)
IV. Physicians’ interpersonal and technical skillsa 75 (67-92)
16. Frequency of physicians’ visits, n (%)b 153 (83.6)
17. Physicians introduced themselves, n (%)b 140 (76.5)
18. Physicians’ technical skills, n (%)b 182 (97.2)
19. Given explanation before being examined, n (%)b 163 (89.6)
V. Living arrangementsa 78 (67-89)
20. Quietness, n (%)b 155 (82.9)
21. Comfort of room, n (%)b 160 (87.0)
22. Quality of food, n (%)b 155 (82.9)
23. Cleanliness, n (%)b 175 (93.6)
24. Staff knocked on the door, n (%)b 161 (91.0)
25. Respect of privacy, n (%)b 175 (92.6)
VI. Conveniencea 78 (67-89)
26. Administrative admission process, n (%)b 170 (92.4)
27. Quality of care provided by x-ray staff, n (%)b 144 (93.5)
28. Finding one’s way within the hospital building, n (%)b 134 (75.3)
29. Test coordination and scheduling, n (%)b 157 (89.7)
Overalla 77 (68-87)
Notes: aData are median (25th-75th percentiles). Patient perception scores range between 0 and 100,
with higher scores denoting better rating; bdata are patient numbers (percentages) very or fairly
satisfied. Values were missing for the following items: nurses’ availability (n ¼ 4), nurses’ courtesy
(n ¼ 1), prompt response to call button (n ¼ 17), pain control (n ¼ 27), nurse technical skills (n ¼ 3),
nurse interest in patient’s worries and needs (n ¼ 3), waiting time following admission (n ¼ 1),
information about medication side effects (n ¼ 18), information about test or treatment purpose (n ¼ 6),
communicating tests results (n ¼ 11), information provision in an understandable way (n ¼ 13),
information on recovery process (n ¼ 35), instructions about medical follow-up (n ¼ 21), discharge
procedure efficiency (n ¼ 7), providing information to family members (n ¼ 24), frequency of physician
visits (n ¼ 8), physicians introduced themselves (n ¼ 8), physician technical skills (n ¼ 4), given
explanation before being examined (n ¼ 9), quietness (n ¼ 4), room comfort (n ¼ 7), food quality (n ¼ 4),
Table AI. cleanliness (n ¼ 4), staff knocked on the door (n ¼ 14), respect of privacy (n ¼ 2), administrative
Patients’ hospital care admission process (n ¼ 7), care quality provided by x-ray staff (n ¼ 37), finding one’s way within the
quality perceptions hospital building (n ¼ 13) and test coordination and scheduling (n ¼ 16)
Standards Description Exclusion criteria

Overall medical Composite score computed as the number of standards receiving a “yes” Discharge from an emergency department
record-keeping score score divided by the number of applicable standards: observation unit
1. Presence of hospital admission entry (clerking): yes/no
Appendix 2

2. Complete hospital admission entry (clerking): yes/noa

3. Complete medication orders: yes/nob
4. Presence of surgical or invasive procedure notes: yes/no/na
5. Presence of delivery notes: yes/no/na
6. Complete anesthetic record: yes/no/nac
7. Complete blood transfusion record: yes/no/na
8. Complete discharge medication order: yes/no/nad
9. Complete discharge summary: yes/noe
10. Medical record structured and organized: yes/no
Range: 0-100, with higher scores denoting better compliance
Pain assessment Documentation of pain assessment status consisting of at least one Discharge from an emergency department
documentation evaluation in a painless patient and two evaluations in a painful patient. observation unit
Each evaluation should be performed using a pain assessment scale (visual
analog scale or other)
Nutritional disorder Documentation of body weight Age o18 years
screening Discharge from an emergency department
documentation observation unit
Length of stay o2 days
Transfer to an intensive care unit, observation unit,
palliative care unit, or obstetrics department within
two days of admission
Timely discharge Presence of a complete discharge summary in the medical record, dated Discharge from an emergency department
summary completion within eight days following dischargee observation unit
Discharge by death

Notes: na, not applicable. aComplete hospital admission entry included: (1) reason for admission and presenting complaints; (2) past medical history and relevant risk
factors; (3) current medications; and (4) concluding notes from the clerking physician; bcomplete medication order included: (1) patient first and last name; (2) date;
(3) physician signature; (4) physician last name; (5) drug name; (6) dosage; and (7) administration route. All medication orders made within the first 72 h following hospital
admission were assessed for completeness. cComplete anesthetic record included: (1) preanesthesia evaluation documentation; (2) intraoperative notes; and (3) postoperative
assessment. dComplete discharge medication order included: (1) patient first and last name; (2) date; (3) physician signature; (4) physician last name; (5) drug name; (6) dosage;
(7) administration route; and (8) treatment duration. eComplete discharge summary included: (1) patient’s general practitioner name and address; (2) admission and discharge
dates; (3) diagnosis and management; and (4) discharge medication regimen
Medical

Medical record-keeping
record-keeping

standards
Table AII.
543
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