PEDIATRICS Vol. 56 No. 2 August 1975, pp. 295-296
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A Limitation in the Use of Office Records for Health Care Evaluation

Thomas Long M.D.1 and K. D. Rogers M.D.1

1 Department of Community Medicine, School of Medicine, University of Pittsburgh Pittburgh, Pennsylvania

A potential limitation of physician office records for ambulatory health care evaluation is their completeness. Criteria used to evaluate care of a specific problem not only should be of major importance in its diagnosis and treatment but should also be likely to be recorded in the physician's records. It is possible that a physician may not record certain kinds of observations and actions even though he performs them. Further, whether or not the physician enters information in his record may not be related to his opinion about its importance for patient care.

The specific questions asked in this study were whether practices deemed desirable by practitioners for diagnosis and management of sore throat of possible streptococcal origin were actually performed and, if so, whether the performance was recorded.




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