Auditing Problem-Oriented Records and Traditional Records

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Abstract
Although problem-oriented records are increasingly popular, few studies have objectively compared their advantages to those of traditional, source-oriented records. To compare the speed and accuracy with which records in these two formats can be audited, medical records of four hospitalized patients with complex general medical problems were adapted into problem-oriented and source-orient formats of comparable length and content and presented to 36 medical house staff from two teaching hospitals. Three dependent variables were measured: time taken to read each record and to answer 10 factual questions on its content; accuracy in answering these questions; and proportion of independently determined major errors in medical care recognized in each case history after one reading. No significant differences were observed between the performance of the two records. Arguments for or against widespread adoption of problem-oriented records should be based on factors other than the speed and accuracy with which they can be audited. (N Engl J Med 290:829–833, 1974)

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