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What does the medical record reveal about functional status?

A comparison of medical record and interview data

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Abstract

OBJECTIVE: Functional status measures are potent independent predictors of hospital outcomes and mortality. The study objective was to compare medical record with interview data for functional status.

SUBJECTS AND METHODS: Subjects were 525 medical patients, aged 70 years or older, hospitalized at an academic medical center. Patient interviews determined status for 7 basic activities of daily living (BADLs) and 7 instrumental activities of daily living (IADLs). Medical records were reviewed to assess documentation of BADLs and IADLs.

RESULTS: Most medical records contained no documentation of individual BADLs and IADLs (61% to 98% of records lacking documentation), with the exception of walking (24% of medical records lacking documentation). Impairment prevalence was lower in medical records than at interview for all BADLs and IADLs, and agreement between interview and medical record was poor (κ<0.40 for individual BADLs and IADLs). Sensitivity of the medical record for BADL and IADL impairment was poor (range 95% to 44%), using the interview as a reference standard. Sensitivity and specificity of the medical record for detection of BADL and IADL impairment changed substantially when records with nondocumentation of functional status were excluded or were assumed to be equivalent to independence.

CONCLUSIONS: The results suggest that the medical record is a poor source of data on many functional status measures, and that assuming that nondocumentation of functional status is equivalent to independence may be unwarranted. Given the prognostic importance of functional status measures, the results highlight the importance of developing reliable and efficient means of obtaining functional status information on hospitalized older patients.

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References

  1. Inouye SK, Peduzzi PN, Robison JT, Hughes JS, Horwitz RI, Concato J. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA. 1998;279:1187–93.

    Article  PubMed  CAS  Google Scholar 

  2. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL, a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.

    PubMed  CAS  Google Scholar 

  3. Lawton MP, Brady EM. Assessment of older people: self-maintaining instrumental activities of daily living. Gerontologist. 1969;9:179–86.

    PubMed  CAS  Google Scholar 

  4. Covinsky KE, Justice AC, Rosenthal GE, Palmer RM, Landefeld CS. Measuring prognosis and case mix in hospitalized elders: the importance of functional status. J Gen Intern Med. 1997;12:203–8.

    PubMed  CAS  Google Scholar 

  5. Inouye SK, Wagner DR, Acampora D, et al. A predictive index for functional decline in hospitalized elderly medical patients. J Gen Intern Med. 1993;8:645–52.

    Article  PubMed  CAS  Google Scholar 

  6. Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med. 1993;119:474–81.

    PubMed  CAS  Google Scholar 

  7. Fields SD, MacKenzie CR, Charlson ME, Sax FL. Cognitive impairment: can it predict the course of hospitalized patients? J Am Geriatr Soc. 1986;34:579–85.

    PubMed  CAS  Google Scholar 

  8. Keeler EB, Kahn KL, Draper D, et al. Changes in sickness at admission following the introduction of the prospective payment system. JAMA. 1990;264:1962–8.

    Article  PubMed  CAS  Google Scholar 

  9. Daley J, Jencks S, Draper D, Lenhart G, Thomas N, Walker J. Predicting hospital-associated mortality for Medicare patients. JAMA. 1988;260:3617–24.

    Article  PubMed  CAS  Google Scholar 

  10. Winograd CH, Gerety MB, Chung M, Goldstein MK, Dominguez F, Vallone R. Screening for frailty: criteria and predictors of outcomes. J Am Geriatr Soc. 1991;39:778–84.

    PubMed  CAS  Google Scholar 

  11. Narain P, Rubenstein LZ, Wieland GD, et al. Predictors of immediate and 6-month outcomes in hospitalized elderly patients: the importance of functional status. J Am Geriatr Soc. 1988;36:775–83.

    PubMed  CAS  Google Scholar 

  12. Gillick MR, Serrell NA, Gillick LS. Adverse consequences of hospitalization in the elderly. Soc Sci Med. 1982;16:1033–8.

    Article  PubMed  CAS  Google Scholar 

  13. Davis RB, Iezzoni LI, Phillips RS, Reiley P, Coffman GA, Safran C. Predicting in-hospital mortality: the importance of functional status information. Med Care. 1995;33:906–21.

    Article  PubMed  CAS  Google Scholar 

  14. Pinholt EM, Kroenke K, Hanley JF, Kussman MJ, Twyman PL, Carpenter JL. Functional assessment of the elderly: a comparison of standard instruments with clinical judgment. Arch Int Med. 1987;147:484–8.

    Article  CAS  Google Scholar 

  15. Rubenstein LZ, Calkins DR, Young RT, et al. Improving patient function: a randomized trial of functional disability screening. Ann Int Med. 1989;111:836–42.

    PubMed  CAS  Google Scholar 

  16. Rubenstein LZ, Schairer C, Wieland GD, Kane R. Systematic biases in functional status: effects of different data sources. J Gerontol. 1984;39:686–91.

    PubMed  CAS  Google Scholar 

  17. Stewart MA, Buck CW. Physicians’ knowledge and response to patients’ problems. Med Care. 1977;15:578–85.

    Article  PubMed  CAS  Google Scholar 

  18. Nelson E, Conger B, Douglass R, et al. Functional health status levels of primary care patients. JAMA. 1983;249:3331–8.

    Article  PubMed  CAS  Google Scholar 

  19. Wartman SA, Morlock LL, Malitz FE, Palm E. Impact of divergent evaluations of physicians and patients of patients’ complaints. Public Health Rep. 1983;98:141–5.

    PubMed  CAS  Google Scholar 

  20. Calkins DR, Rubenstein LZ, Cleary PD, et al. Failure of physicians to recognize functional disability in ambulatory patients. Ann Intern Med. 1991;114:451–4.

    PubMed  CAS  Google Scholar 

  21. Elam JT, Bever T, El Derwi D, et al. Comparison of sources of functional report with observed functional ability of frail older persons. Gerontologist. 1989;29(suppl):308A.

    Google Scholar 

  22. Burns RB, Moskowitz MA, Ash A, Kane RL, Finch MD, Bak SM. Self-report versus medical record functional status. Med Care. 1992;30:85–95.

    Article  Google Scholar 

  23. Eden BM, Foreman MD. Problems associated with underrecognition of delirium in critical care: a case study. Heart Lung. 1996;25:388–400.

    Article  PubMed  CAS  Google Scholar 

  24. Inouye SK. The recognition of delirium. Hosp Pract. 1991;26:61–2.

    CAS  Google Scholar 

  25. Inouye SK. The dilemma of delirium: clinical and research controversies regarding the diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med. 1994;97:278–88.

    Article  PubMed  CAS  Google Scholar 

  26. Johnson JC, Kerse NM, Gottlieb GL, Wanich C, Sullivan E, Chen K. Prospective versus retrospective methods of identifying patients with delirium. J Am Geriatr Soc. 1992;40:316–9.

    PubMed  CAS  Google Scholar 

  27. Gustafson Y, Brannstrom B, Norberg A, Bucht G, Winblad B. Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients. J Am Geriatr Soc. 1991;39:760–5.

    PubMed  CAS  Google Scholar 

  28. Dollear W, Gorelick PB, Harris Y, Miles T, Bozzola F. Vascular dementia: a clinical and death certificate study. Neuroepidemiol. 1991;11:53–8.

    Google Scholar 

  29. Cooper B, Bickel H, Schaufele M. The ability of general practitioners to detect dementia and cognitive impairment in their elderly patients. A study in Mannheim. Int J Geriatr Psych. 1992;7:591–8.

    Article  Google Scholar 

  30. Rawson NSB, Malcolm E, D’Arcy C. Reliability of the recording of schizophrenia and depressive disorder in the Saskatchewan health care datafiles. Soc Psychiatry Psychiatr Epidemiol. 1997;32:191–9.

    Article  PubMed  CAS  Google Scholar 

  31. Jorm AF. The epidemiology of depressive states in the elderly: implications for recognition, intervention, and prevention. Soc Psychiatry Psychatr Epidemiol. 1995;30:53–9.

    Article  CAS  Google Scholar 

  32. Koenig HG, Meador KB, Cohen JH, Blazer DG. Detection and treatment of major depression in older medically ill hospitalized patients. Int J Psychiatry Med. 1988;18:17–31.

    Article  PubMed  CAS  Google Scholar 

  33. Jackson R, Baldwin B. Detecting depression in elderly medically ill patients: the use of the Geriatric Depression Scale compared with medical and nursing observations. Age Aging. 1993;22:349–53.

    Article  CAS  Google Scholar 

  34. Schieve LA, Perry GS, Cogswell ME, et al. Validity of self-reported pregnancy delivery weight: an analysis of the 1988 National Maternal and Infant Health Survey. NMIHS Collaborative Working Group. Am J Epidemiol. 1999;150:947–56.

    PubMed  CAS  Google Scholar 

  35. Bergmann MM, Byers T, Freedman DS, Mokdad A. Validity of self-reported diagnoses leading to hospitalization: a comparison of self-reports with hospital records in a prospective study of American adults. Am J Epidemiol. 1998;147:969–77.

    PubMed  CAS  Google Scholar 

  36. Olson JE, Shu XO, Ross JA, Pendergrass T, Robison LL. Medical record validation of maternally reported birth characteristics and pregnancy-related events: a report from the Children’s Cancer Group. Am J Epidemiol. 1997;145:58–67.

    PubMed  CAS  Google Scholar 

  37. Nevitt MC, Cummings SR, Browner WS, et al. The accuracy of self-report of fractures in elderly women: evidence from a prospective study. Am J Epidemiol. 1992;135:490–9.

    PubMed  CAS  Google Scholar 

  38. Wallihan DB, Stump TE, Callahan CM. Accuracy of self-reported health services use and patterns of care among urban older adults. Med Care. 1999;37:662–70.

    Article  PubMed  CAS  Google Scholar 

  39. Wagner DP, Knaus WA, Draper EA. Statistical validation of a severity of illness measure. Am J Public Health. 1983;73:878–84.

    Article  PubMed  CAS  Google Scholar 

  40. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275:852–7.

    Article  PubMed  CAS  Google Scholar 

  41. Myers AH, Baker SP, VanNatta ML, Abbey H, Robinson EG. Risk factors associated with falls and injuries among elderly institutionalized persons. Am J Epidemiol. 1991;133:1179–90.

    PubMed  CAS  Google Scholar 

  42. Folstein MF, Folstein SE, McHugh PR. The Folstein Mini-Mental State Examination: a practical method for grading the cognitive state of patients for the clinician. J Psychatr Res. 1975;12:189–98.

    Article  CAS  Google Scholar 

  43. Sheikh JI, Yeseavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73.

    Article  Google Scholar 

  44. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.

    Article  PubMed  CAS  Google Scholar 

  45. Charlson ME, Pompei P, Alessi KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    Article  PubMed  CAS  Google Scholar 

  46. Sager MA, Franke T, Inouye SK, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med. 1996;156:645–52.

    Article  PubMed  CAS  Google Scholar 

  47. Sager MA, Rudberg MA, Jalaluddin M, et al. Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc. 1996;44:251–7.

    PubMed  CAS  Google Scholar 

  48. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332:1338–44.

    Article  PubMed  CAS  Google Scholar 

  49. Fleiss JL. Statistical Methods for Rates and Proportions. New York: John Wiley and Sons; 1981.

    Google Scholar 

  50. Magaziner J, Simonsick EM, Kashner TM, Hebel JR. Patient-proxy response comparability on measures of patient health and functional status. J Clin Epidemiol. 1988;41:1065–74.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Internal Medicine (Geriatrics), Yale University School of Medicine, 20 York St., Tompkins 15, 06504, New Haven, CT

    Sidney T. Bogardus Jr. MD & Sharon K. Inouye MD, MPH

  2. the Program on Aging, Yale University School of Medicine, New Haven, Conn.

    Virginia Towle MPhil, Christianna S. Williams MPH & Mayur M. Desai PhD

Authors
  1. Sidney T. Bogardus Jr. MD
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  2. Virginia Towle MPhil
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  3. Christianna S. Williams MPH
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  4. Mayur M. Desai PhD
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  5. Sharon K. Inouye MD, MPH
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Correspondence to Sidney T. Bogardus Jr. MD.

Additional information

This work was supported in part by a grant from the National Institute on Aging (#RO1 AG12551), and by the Claude D. Pepper Older Americans Independence Center at Yale (#P60 AG10469). Dr. Bogardus is a recipient of a Pfizer/American Geriatrics Society Postdoctoral Fellowship for Research on Health Outcomes in Geriatrics. Dr. Inouye is a recipient of a Midcareer Award (#K24 AG00949) from the National Institute on Aging and a Donaghue Investigator Award (#DF98-105) from the Patrick and Catherine Weldon Donaghue Medical Research Foundation.

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Bogardus, S.T., Towle, V., Williams, C.S. et al. What does the medical record reveal about functional status?. J GEN INTERN MED 16, 728–736 (2001). https://doi.org/10.1111/j.1525-1497.2001.00625.x

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  • DOI: https://doi.org/10.1111/j.1525-1497.2001.00625.x

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