To compare paper and electronic records, the authors employed an experienced surgeon to code diagnoses and procedures in the paper-based records without knowledge of the medical data in the electronic abstracts.
A gold standard representing the truth regarding the patient should be the reference point for the comparison of medical record types. This would allow the comparison of sensitivity and specificity on levels II and III in ▶.
Comparison of electronically available data with the paper record often is called validation.14Hassey et al.15used different references for different parts of the record in their study on validity of electronic patient records in a general practice.