Can the decision to operate be judged retrospectively? A study of medical records

Abstract

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. Subjects: 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.