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Volume 15 (1)
Volume 15, Issue 1, March 1995 
J Contin Educ Health Prof 1995; 15(1):31-38
ORIGINAL ARTICLES
 JCEHP AWARD FOR EXCELLENCE IN RESEARCH
Full Text 
Patient Charts and Physician Office Management Decisions: Chart Audit and Chart Stimulated Recall Penny A. Jennett, PhD Susan M. Scott Martin A. Atkinson, MD Rodney A. Crutcher, MD David B. Hogan, MD R. Wayne Elford, MD Keith L. MacCannell, MD John S. Baumber, PhD, MD A b s t r a c t Accurate assessment of clinical competence and performance in office practice is enhanced through a multi-tool approach. Two assessment tools that offer a complementary range of information, specific to the patient’s chart, are chart audit (CA) and chart stimulated recall (CSR). This paper demonstrates how chart audit and chart stimulated recall provide insights into the office management of osteoarthritis in the elderly. CA provides basic data for clinical choices when the areas of problem identification, history, physical, investigations, and treatments are examined. CSR illuminates the rationale behind decisions, as well as the choices considered and the options ruled out. Furthermore, CSR shows how individual patient and physician characteristics, practice and professional factors, and health care system and social factors, are influential variables on the physician’s clinical management decisions. Supplementing the type of data extracted from the CA with those found through CSR allows for a broad range of information to be used in assessing a physician’s ability to make clinical decisions. Physicians, educators, and assessors, will benefit from considering the value of using both of these patient chart approaches when reviewing clinical care. Keywords: Assessment tools; chart audit; chart stimulated recall; clinical competence; NSAID gastropathy; osteoarthritis; patient chart |
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