Grace, Sherry L.Alter, DavidHigginson, LyallSuskin, NevilleStewart, Donna EileenGravely-Witte, Shannon2009-05-262009-05-262008-10Journal of Clinical Epidemiology, 61(10), 1073-1079. October 20080895-4356http://hdl.handle.net/10315/2559https://dx.doi.org/10.1016/j.jclinepi.2007.11.017Objective: To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report. Study Design and Setting: A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance. Results: With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's K, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history. Conclusion: Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.enRisk factorsCardiologistConcordanceCompletenessPatient self-reportMedical chartsArticle