What proportion of the data in the patient’s medical record is captured

Contact a health care facility (hospital, nursing home, physicians’ office, or other facility) to ask permission to view a sample of the health records it maintains. These records may be in paper or electronic form. For each record, answer the following questions about data quality:

a. How would you assess the quality of the data in the patient’s record?

b. What proportion of the data in the patient’s medical record is captured electronically? What information is recorded manually? Do you think the method of capture affects the quality of the information?

c. How does the data quality compare with what you expected?