Article: article from journal or magazin.
Can the decision to operate be judged retrospectively? A study of medical records.
The European Journal of Surgery
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. SUBJECT: 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.
Female, Humans, Intervertebral Disk Displacement, Lumbar Vertebrae, Male, Medical Records, Middle Aged, Process Assessment (Health Care), Retrospective Studies, Surgical Procedures, Operative
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