The Correctness of the Data can be Verified

This criterion examines whether the information required for the calculation of the quality indicator can be found in a properly managed patient record. If this is not the case, a validation of the clinical routine data cannot be performed on the basis of the patient chart and therefore the correctness of the data cannot be verified. In the end, this could raise doubts as to the meaningful use of the quality indicators.

This criterion examines not explicitly the actual documentation quality but the possibility to verify the correctness. A good data quality is indeed a generally recognized and often considered prerequisite for the use of quality indicators, but it is not a characteristic of the quality indicator itself and thus not a criterion for quality indicators.

The gold standard by which this criterion is measured is the reference documentation, using clinical routine data from the patient chart and not the treatment itself. This is standard practice because the reproducibility of treatment processes and outcomes is only possible through recordings in patient charts.

Definition
A procedure is available with which the agreement of the documentation with reality or a reference, for example a patient chart, can be examined.

Core Statement
The following statement is assessed: “The correctness of the data can be examined.”

Information Base for the Assessment
The assessment of the core statement results from the standard documentation of treatment courses, which is drawn upon as a reference. Therefore, the patient chart serves as the reference or the “gold standard” for the clinical routine data.

Assessment Process
After all evaluators have acknowledged and understood the information base, they assess the core statement.

A detailed process description can be found in Appendix 2.

Assessment Stages
Applies
Does not apply
Abstention