Concordance between self-report and medical records of preventive healthcare delivery among a sample of disadvantaged patients from four aboriginal community controlled health services

Abstract

Background This cross-sectional study aimed to explore, among a sample of patients attending one of four Aboriginal Health Services (ACCHSs), the degree of concordance between self-report and medical records for whether screening for key healthcare items had ever been undertaken or had been undertaken within the recommended timeframe.

Methods Across the four ACCHSs, a convenience sample of 109 patients was recruited. Patients completed a self-report computer survey assessing when they last had preventive care items undertaken at the service. ACCHS staff completed a medical record audit for matching items. The degree of concordance (i.e. the percentage of cases in which self-reports matched responses from the medical record) was calculated.

Results Concordance was relatively high for items including assessment of Body Mass Index and blood pressure, but was substantially lower for items including assessment of waist circumference, alcohol intake, physical activity, and diet.

Conclusions Reliance on either patient self-report or medical record data for assessing the level of preventive care service delivery by ACCHSs requires caution. Efforts to improve documentation of some preventive care delivery in medical records are needed. These findings are likely to also apply to patients in other general practice settings