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OBJECTIVE:

To determine whether feedback from attending physicians to residents about outpatient medical records improves chart documentation and quality of care.

DESIGN:

Cross-sectional study with repeated measures.

SETTING:

Primary care internal medicine clinic at a metropolitan community hospital.

PATIENT/PARTICIPANTS:

Fifteen interns and 20 residents.

INTERVENTION:

Attending physicians reviewed at least two charts for each resident on three occasions about 4 months apart and then discussed their findings with the residents.

MEASUREMENTS AND MAIN RESULTS:

Explicit criteria defined the extent of chart documentation and the comprehensiveness of care delivery. Attending physicians also made a subjective assessment of the overall quality of care. All results were converted to 0-to-1 scales. From the first to the third period, chart documentation increased from 0.60 to 0.86 (p < .001), but there were no significant changes in the delivery of care or in the subjective assessments of the overall quality of care.

CONCLUSIONS:

Both review of residents’ outpatient medical records and periodic feedback from attending physicians improve how well medical housestaff document care in the chart.

KEY WORDS: documentation; quality of care; feedback; outpatients.