Diagnostic information available in university and community hospital medical records: Patients with cerebrovascular disease

Abstract

Medical records of 1,117 patients with cerebrovascular disease from one university and four community hospitals were abstracted by trained, nonphysician personnel at the rate of four cases per hour. The data obtained were adequate to describe eight cerebrovascular disease syndromes. In 56% of cases, data from the body of the medical record failed to support the hospital’s discharge diagnosis. The eight study diagnoses were not identical with pathological diagnoses, but their characteristics suggest that they are distinct and related to recognized cerebrovascular disease entities. It is recommended that evaluations of diagnostic and therapeutic practice for stroke patients be carried out separately for each of the study syndromes; the care expected and the outcome observed are different for each. © 1972 American Heart Association, Inc.