ArticleBMJ quality & safety2020
Using standardised patients to assess the quality of medical records: an application and evidence from rural China.
Article in BMJ quality & safety, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers.
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Who cites it
7 citing papers in PubMed.
- Early insulin combined with metformin therapy and long-term risks of cardiovascular disease, kidney disease, and cancer in newly diagnosed type 2 diabetes: a real-world cohort study in China.Frontiers in endocrinology · 2026Article
- Antibiotic Prescribing Decisions for Upper Respiratory Tract Infections Among Primary Healthcare Physicians in China: A Mixed-Methods Approach Based on the Theory of Planned Behavior.Antibiotics (Basel, Switzerland) · 2024Article
- Integrated database-based Screening Cohort for Asian Nomadic descendants in China (Scan-China): Insights on prospective ethnicity-focused cancer screening.Epidemiology and health · 2023Article
- Experiences of operational managers regarding record keeping by new professional nurses in public hospitals in the North West province, South Africa.Health SA = SA Gesondheid · 2023Article
- The Agreement Between Virtual Patient and Unannounced Standardized Patient Assessments in Evaluating Primary Health Care Quality: Multicenter, Cross-sectional Pilot Study in 7 Provinces of China.Journal of medical Internet research · 2022Article
- The know-do gap in quality of health for chronic non-communicable diseases in rural China.Frontiers in public health · 2022Article
- A Cross-Sectional Analysis of High-Acuity Professional Services Performed by Urban and Rural Emergency Care Physicians Across the United States.Annals of emergency medicine · 2021Article
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Authors and funding
10 authors.
Funding
Abstract
backgroundMedical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries.
objectiveTo provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.
methodsA sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.
resultsMedical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider's income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β -0.87, 95% CI -1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness.
conclusionDespite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.
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