Background Physicians’ adherence to cardiovascular (CV) guidelines has
been found to be poor. In this regard, accuracy in keeping medical records could
play an important role. This study was devised to describe which data are
present in medical records from a large sample of physicians and to investigate
the association and the link between completeness in recording and clinical
appropriateness.
Methods The data extracted from medical records of 1078 doctors (general
practitioners, cardiologists, and diabetologists) were analyzed, with a focus on
CV prevention. The percentage of recorded data of several CV clinical variables
was calculated. A multivariate analysis was performed to investigate the
association between doctors’ and patients’ characteristics
and different patterns in recording. Finally, the completeness in recording was
calculated with a score and plotted against three indicators of appropriateness.
Results The only risk factor that achieved a good standard of registration was
blood pressure (89%). Low-density lipoprotein and waist circumference
were largely under-recorded, whereas lifestyle data collection was almost
negligible. Age, specialization, and use of electronic records increase the
accuracy in recording. When one CV risk factor was predominant, the probability
of having other risk factors recorded was reduced. A significant increase in the
proportion of patients treated according to guidelines was found in doctors who
were more accurate in recording.
Conclusion A link exists between accuracy in recording with both quality of care
and adherence to guidelines. Specific training of all doctors in this field
should be considered.
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