Can the Decision to Operate be Judged Retrospectively? A Study of Medical Records

Author： Jeannot Jean-Gabriel Vader John-Paul Porchet François Larequi-Lauber Tania Burnand Bernard

ISSN： 1102-4151

Source： European Journal of Surgery, Vol.165, Iss.6, 1999-07, pp. : 516-521

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Abstract

Objective: To examine the precision and completeness of information in medical records for evaluating the appropriateness of operative indications for lumbar disc surgery.Design: Retrospective review of records.Setting: University department of neurosurgery, Switzerland.Subjects: 100 patients.Interventions: None.Main outcome measures: Proportion of pre-defined, detailed appropriateness criteria present in the records. Proportion of cases that could unequivocally be classified as to the appropriateness of the indication for operation.Results: The criteria were present and precise for 52 of the items (range 9-90); present but imprecise for 38 of the items, and absent for 10. Because of this imprecision, the appropriateness of only 7 of the operative indications could be unequivocally assessed retrospectively.Conclusion: Medical records are of limited use in assessing the appropriate management of care. The process of care should therefore be evaluated prospectively.