Chart documentation quality and its relationship to the validity of administrative data discharge records
Abstract
The validity of administrative data may be vulnerable to how well physicians document medical charts. The objective of this study is to determine the relationship between chart documentation quality and the validity of administrative data. The charts for patients who underwent carotid endarterectomy were re-abstracted and rated for the quality of documentation. Poorly and well-documented charts were compared by patient, physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of the 2061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics. The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid administrative data, which reduces the communication of clinical information among healthcare providers.
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Variability in the quality of documentation can impact patient outcomes and continuity of care.
“Moreover, the variability in the quality of documentation—ranging from omissions of critical details to inconsistent formatting—can impact patient outcomes and continuity of care [10, 11].”
From Artificial Intelligence (AI) – Powered Documentation Systems in Healthcare: A Systematic Review (2025) · cites this paper as [11]
Cites
Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data
Quan, H., Sundararajan, V., Halfon, P., Fong, A., Burnand, B., Luthi, J.-C., Saunders, L. D., Beck, C. A., Feasby, T. E., & Ghali, W. A. (2005) · Medical Care · doi:10.1097/01.mlr.0000182534.19832.83 · Cited by 10,669 · see citing works
Self-citationEconometric Theory and Methods
Davidson, R., & MacKinnon, J. G. (2003) · Cited by 1,782 · see citing works
Peabody, J. W., Luck, J., Glassman, P., Dresselhaus, T., & Lee, M. (2000) · Journal of the American Medical Association (JAMA) · doi:10.1001/jama.283.13.1715 · Cited by 1,311 · see citing works
A review of uses of health care utilization databases for epidemiologic research on therapeutics
Schneeweiß, S., & Avorn, J. (2005) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2004.10.012 · Cited by 1,290 · see citing works
Measuring Diagnoses: ICD Code Accuracy
O’Malley, K. J., Cook, K. F., Price, M. D., Wildes, K. R., Hurdle, J. F., & Ashton, C. M. (2005) · Health Services Research · doi:10.1111/j.1475-6773.2005.00444.x · Cited by 1,123 · see citing works
Electronic Health Record Use and the Quality of Ambulatory Care in the United States
Linder, J. A., Ma, J., Bates, D. W., Middleton, B., & Stafford, R. S. (2007) · Archives of Internal Medicine · doi:10.1001/archinte.167.13.1400 · Cited by 438 · see citing works
Luck, J., Peabody, J., Dresselhaus, T., Lee, M., & Glassman, P. (2000) · American Journal of Medicine · doi:10.1016/s0002-9343(00)00363-6 · Cited by 342 · see citing works
Quality of morbidity coding in general practice computerized medical records: a systematic review
Jordan, K. P. (2004) · Family Practice · doi:10.1093/fampra/cmh409 · Cited by 198 · see citing works
Data Quality in an Information-Rich Environment: Canada as an Example
Roos, L. L., Gupta, S., Soodeen, R., & Jebamani, L. S. (2005) · Canadian Journal on Aging / La Revue canadienne du vieillissement · doi:10.1353/cja.2005.0055 · Cited by 193 · see citing works
Rethans, J., MARTIN, E. G., & Metsemakers, J. F. M. (1994) · PubMed · Cited by 113 · see citing works
An evaluation of vignettes for predicting variation in the quality of preventive care
Dresselhaus, T. R., Peabody, J. W., Luck, J., & Bertenthal, D. (2004) · Journal of General Internal Medicine · doi:10.1007/s11606-004-0003-2 · Cited by 113 · see citing works
Assessing the reliability of epidemiologic data obtained from medical records
Horwitz, R. I., & Yu, E. (1984) · Journal of Chronic Diseases · doi:10.1016/0021-9681(84)90015-8 · Cited by 100 · see citing works
Electronic Health Record Components and the Quality of Care
Keyhani, S., Hebert, P. L., Ross, J. S., Federman, A. D., Zhu, C. W., & Siu, A. L. (2008) · Medical Care · doi:10.1097/mlr.0b013e31817e18ae · Cited by 92 · see citing works
Hospital and Surgeon Determinants of Carotid Endarterectomy Outcomes
Feasby, T. E., Quan, H., & Ghali, W. A. (2002) · Archives of Neurology · doi:10.1001/archneur.59.12.1877 · Cited by 80 · see citing works
Self-citationWu, L., & Ashton, C. M. (1997) · Evaluation & the Health Professions · doi:10.1177/016327879702000203 · Cited by 77 · see citing works
Interobserver variability in medical record review: An epidemiological study of asthma
Beard, C. M., Yunginger, J. W., Reed, C. E., O’Connell, E. J., & Silverstein, M. D. (1992) · Journal of Clinical Epidemiology · doi:10.1016/0895-4356(92)90117-6 · Cited by 74 · see citing works
Dresser, M., Feingold, L., Rosenkranz, S. L., & Coltin, K. L. (1997) · Medical Care · doi:10.1097/00005650-199706000-00001 · Cited by 59 · see citing works
Identifying undiagnosed diabetes: cross-sectional survey of 3.6 million patients' electronic records
Holt, T., Stables, D., Hippisley‐Cox, J., O’Hanlon, S., & Majeed, A. (2008) · British Journal of General Practice · doi:10.3399/bjgp08x277302 · Cited by 51 · see citing works
Quan, H., Drösler, S. E., Sundararajan, V., Wen, E., Burnand, B., Couris, C. M., Halfon, P., Januel, J., Kelley, E., Klazinga, N., et al. (2008) · IRIS · Cited by 46 · see citing works
Self-citationKennedy, J. (2004) · Canadian Medical Association Journal · doi:10.1503/cmaj.1040170 · Cited by 36 · see citing works
Self-citationMcGreer, E., & Vigers, G. A. (1983) · doi:10.1520/stp33528s · Cited by 32 · see citing works
The Hazards of Using Administrative Data to Measure Surgical Quality
Fry, D. E., Pine, M. B., Jordan, H. S., Hoaglin, D. C., Jones, B., & Meimban, R. J. (2006) · The American Surgeon · doi:10.1177/000313480607201109 · Cited by 27 · see citing works
ICES Report: Using Data from Electronic Medical Records: Theory versus Practice
Mitiku, T., & Tu, K. (2008) · Healthcare Quarterly · doi:10.12927/hcq.2008.20088 · Cited by 18 · see citing works
An audit tool for assessing the appropriateness of carotid endarterectomy
Kennedy, J., Quan, H., Feasby, T. E., & Ghali, W. A. (2004) · BMC Health Services Research · doi:10.1186/1472-6963-4-17 · Cited by 17 · see citing works
Self-citationCIOs and the D.R.I.P. (data-rich, information-poor) syndrome.
Reed, W. C. (1995) · PubMed · Cited by 2 · see citing works
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Bracken, A., Reilly, C., Feeley, A., Sheehan, E., Merghani, K., & Feeley, I. (2025) · Journal of Medical Systems · doi:10.1007/s10916-025-02157-4 · Cited by 113 · see citing works
“Moreover, the variability in the quality of documenta-tion—ranging from omissions of critical details to inconsistent formatting—can impact patient outcomes and continuity of care [10, 11].”
Burles, K., Innes, G. D., Senior, K., Lang, E., & McRae, A. D. (2017) · BMC Medical Research Methodology · doi:10.1186/s12874-017-0361-1 · Cited by 104 · see citing works
Strategies for improving physician documentation in the emergency department: a systematic review
Lorenzetti, D., Quan, H., Lucyk, K., Cunningham, C., Hennessy, D. A., Jiang, J., & Beck, C. A. (2018) · BMC Emergency Medicine · doi:10.1186/s12873-018-0188-z · Cited by 106 · see citing works
Self-citationQuan, H., Eastwood, C. A., Cunningham, C., Liu, M., Flemons, W. W., Coster, C. D., Ghali, W. A., & for the IMECCHI investigators (2013) · BMJ Open · doi:10.1136/bmjopen-2013-003716 · Cited by 64 · see citing works
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Oravec, C. S., Motiwala, M., Reed, K., Kondziolka, D. S., Barker, F. G., Michael, L. M., & Klimo, P. (2017) · Neurosurgery · doi:10.1093/neuros/nyx328 · Cited by 59 · see citing works
Doktorchik, C. T. A., Lu, M., Quan, H., Ringham, C., & Eastwood, C. A. (2019) · Health Information Management Journal · doi:10.1177/1833358319855031 · Cited by 49 · see citing works
Self-citationAdeleke, I. T., Adekanye, A. O., Onawola, K. A., Okuku, A. G., Adefemi, S. A., Erinle, S. A., Shehu, A. A., Yahaya, O. E., Adebisi, A. A., James, J. A., et al. (2012) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2012-000823 · Cited by 47 · see citing works
Varela, L. O., Doktorchik, C. T. A., Wiebe, N., Quan, H., & Eastwood, C. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06302-w · Cited by 43 · see citing works
Self-citationIn Reply: Big Data Research in Neurosurgery: A Critical Look at this Popular New Study Design
Oravec, C. S., Motiwala, M., Reed, K., Kondziolka, D. S., Barker, F. G., Michael, L. M., & Klimo, P. (2018) · Neurosurgery · doi:10.1093/neuros/nyy102 · Cited by 41 · see citing works
Wiebe, N., Otero Varela, L., Niven, D. J., Ronksley, P. E., Iragorri, N., & Quan, H. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz081 · Cited by 42 · see citing works
Self-citationPredicting In-Hospital Mortality in Patients Undergoing Complex Gastrointestinal Surgery
Grendar, J. (2011) · Archives of Surgery · doi:10.1001/archsurg.2011.296 · Cited by 35 · see citing works
Hospitalization for Uncomplicated Hypertension: An Ambulatory Care Sensitive Condition
Walker, R. L., Chen, G., McAlister, F. A., Campbell, N. R. C., Hemmelgarn, B. R., Dixon, E., Ghali, W. A., Rabi, D. M., Tu, K., Jetté, N., et al. (2013) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2013.05.002 · Cited by 33 · see citing works
Self-citationInternational Classification of Diseases clinical coding training: An international survey
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Self-citationMonyatsi, G., Mullan, P. C., Phelps, B. R., Tolle, M. A., Machine, E. M., Gennari, F., Makosky, J., & Anabwani, G. M. (2011) · PubMed · Cited by 21 · see citing works
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Wood, D. L. S. R. B. D. R. (2012) · South African Medical Journal · doi:10.7196/samj.5802 · Cited by 19 · see citing works
Chomutare, T., Svenning, T. O., Hernández, M. Á. T., Ngo, P. D., Budrionis, A., Markljung, K., Hind, L. I., Torsvik, T., Mikalsen, K. Ø., Babić, A., et al. (2025) · Journal of Medical Internet Research · doi:10.2196/71904 · Cited by 15 · see citing works
Adeleke, I. T. (2015) · American Journal of Health Research · doi:10.11648/j.ajhr.s.2015030101.16 · Cited by 14 · see citing works
Boulanger, V., MacLaurin, A., & Quach, C. (2024) · Journal of Hospital Infection · doi:10.1016/j.jhin.2024.09.027 · Cited by 13 · see citing works
Yu, A., Quan, H., McRae, A. D., Wagner, G., Hill, M. D., & Coutts, S. B. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-015234 · Cited by 13 · see citing works
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Borzecki, A. M., & Rosen, A. K. (2019) · BMJ Quality & Safety · doi:10.1136/bmjqs-2019-009730 · Cited by 11 · see citing works
Daniels, A., Muloiwa, R., Myer, L., & Buys, H. (2021) · South African Medical Journal · doi:10.7196/samj.2021.v111i2.14686 · Cited by 11 · see citing works
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Jackson, T. J. (2014) · Health Information Management Journal · doi:10.1177/183335831404300201 · Cited by 11 · see citing works
Urquhart, R., Rayson, D., Porter, G. A., & Grunfeld, E. (2011) · Healthcare policy · doi:10.12927/hcpol.2011.22520 · Cited by 9 · see citing works
Refining Hypertension Surveillance to Account for Potentially Misclassified Cases
Peng, M., Chen, G., Lix, L. M., McAlister, F. A., Tu, K., Campbell, N. R. C., Hemmelgarn, B. R., Svenson, L. W., Quan, H., & Hypertension Outcomes Surveillance Team (2015) · PLoS ONE · doi:10.1371/journal.pone.0119186 · Cited by 9 · see citing works
Self-citationDie Validität von Routinedaten zur Qualitätssicherung
Hanisch, E. W., Weigel, T. F., Buia, A., & Bruch, H. ‐. (2015) · Der Chirurg · doi:10.1007/s00104-015-0012-1 · Cited by 8 · see citing works
Chiu, M., MOIST, L. M., Al‐Jaishi, A. A., & Jain, A. K. (2022) · Canadian Journal of Kidney Health and Disease · doi:10.1177/20543581221129465 · Cited by 8 · see citing works
Reid, B. A., Ridoutt, L., O'Connor, P. E., & Murphy, D. (2017) · Health Information Management Journal · doi:10.1177/1833358316687576 · Cited by 7 · see citing works
Chamberlain, C., Fredericks, B. L., McLean, A., Davis, B., Eades, S., Stewart, K., & Reid, C. M. (2013) · Australian and New Zealand Journal of Public Health · doi:10.1111/1753-6405.12148 · Cited by 6 · see citing works
Roder, D. M., & Buckley, E. S. (2017) · Asia-Pacific Journal of Clinical Oncology · doi:10.1111/ajco.12644 · Cited by 4 · see citing works
Wing, A., Hill-Taylor, B. J., SKETRIS, I. S., Smith, J., Stewart, S. A., & Hurley, K. F. (2012) · The Canadian Journal of Hospital Pharmacy · doi:10.4212/cjhp.v65i4.1156 · Cited by 3 · see citing works
Wiebe, N., Xu, Y., Shaheen, A. A., Eastwood, C., Boussat, B., & Quan, H. (2020) · International Journal for Population Data Science · doi:10.23889/ijpds.v5i3.1352 · Cited by 3 · see citing works
Self-citationAlanazi, A. T., Alkhaibari, E. A., & Aldosari, B. (2023) · Cureus · doi:10.7759/cureus.37966 · Cited by 3 · see citing works
Kasaye, M. D., Guadie, H. A., Lashitaw, M., Mengestie, N. D., & Kalayou, M. H. (2022) · Informatics in Medicine Unlocked · doi:10.1016/j.imu.2022.101016 · Cited by 3 · see citing works
Ngo, P. D., Hernández, M. Á. T., Chomutare, T., Budrionis, A., Svenning, T. O., Torsvik, T., Lamproudis, A., & Dalianis, H. (2025) · JMIR AI · doi:10.2196/66153 · Cited by 4 · see citing works
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Lartigue, B., & Catillon, É. (2012) · Transfusion Clinique et Biologique · doi:10.1016/j.tracli.2011.06.004 · Cited by 1 · see citing works
Dziki, Ł. A., Otto, R., Lippert, H., Mroczkowski, P., & Jannasch, O. (2018) · Gastroenterology Research and Practice · doi:10.1155/2018/3925062 · Cited by 1 · see citing works
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Yu, A. (2016) · Libraries and Cultural Resources (University of Calgary) · doi:10.11575/prism/27268
Kondziolka, D. S. (2020) · Springer eBooks · doi:10.1007/978-3-030-34906-6_38
Mugo, J. W., & Uimbia, M. G. (2021) · International Journal of Current Aspects · doi:10.35942/ijcab.v5i1.159
Iverson, R. (2020) · uO Research (University of Ottawa) · doi:10.20381/ruor-25751
Oyekola, A. B., & Susuman, A. S. (2024) · African Journal for Physical Activity and Health Sciences (AJPHES) · doi:10.37597/ajphes.2024.30.1.1
Howard-Williams, E. L., Knight, R., Ossman, P., Younce, D., Donohoe, A., Marucci, L., & Mock, C. (2025) · Health Information Management Journal · doi:10.1177/18333583241309990
Khorrami, F., Karami, N. A., Haghighi, M. H. H., Chahooei, M. K., & Alipour, J. (2025) · Journal of Health Administration · doi:10.61882/jha.27.4.1
Varela, L. O., Doktorchik, C. T. A., Wiebe, N., Quan, H., & Eastwood, C. (2021) · Figshare · doi:10.6084/m9.figshare.14385603
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- Authors
- So, L., Beck, C. A., Brien, S., Kennedy, J., Feasby, T. E., Ghali, W. A., & Quan, H.
- Affiliations
- University of Calgary (CA)
- University of Oxford (GB)
- ORCID
- Hude Quan
- Venue
- Health Informatics Journal
- Publisher
- SAGE Publications
- Published
- 2010-06
- Volume
- 16
- Issue
- 2
- Pages
- 101-113
- ISSN
- 1355-4743 (ISSN-L)
- 1460-4582
- 1741-2811
- OpenAlex
- W2085520376
- Cited by
- 50
- References
- 25
- Citations by year
- 2026: 1 · 2025: 7 · 2024: 2 · 2023: 1 · 2022: 4 · 2021: 4 · 2020: 4 · 2019: 3 · 2018: 3 · 2017: 5 · 2016: 1 · 2015: 4 · 2014: 1 · 2013: 3 · 2012: 4
- FWCI
- 5.98
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Health Informatics Journal (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
- Keywords
- administrative data validity, hospital discharge data, carotid endarterectomy, interobserver agreement, kappa statistic, comorbidities, clinical information exchange
- MeSH terms
- Documentation, Humans, Medical Records, Nurses, Patient Discharge, Reproducibility of Results
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