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Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9).

ABSTRACT: OBJECTIVE: To refine the Physician Documentation Quality Instrument (PDQI) and test the validity and reliability of the 9-item version (PDQI-9). METHODS: Three sets each of admission notes, progress notes and discharge summaries were evaluated by two groups of physicians using the PDQI-9 and an overall general assessment: one gold standard group consisting of program or assistant program directors (n=7), and the other of attending physicians or chief residents (n=24). The main measures were criterion-related validity (correlation coefficients between Total PDQI-9 scores and 1-item General Impression scores for each note), discriminant validity (comparison of PDQI-9 scores on notes rated as best and worst using 1-item General Impression score), internal consistency reliability (Cronbach's alpha), and inter-rater reliability (intraclass correlation coefficient (ICC)). RESULTS: The results were criterion-related validity (r = -.678 to .856), discriminant validity (best versus worst note, t = 9.3, p = .003), internal consistency reliability (Cronbach's alphas = .87-.94), and inter-rater reliability (ICC = .83, CI = .72-.91). CONCLUSION: The results support the criterion-related and discriminant validity, internal consistency reliability, and inter-rater reliability of the PDQI-9 for rating the quality of electronic physician notes. Tools for assessing note redundancy are required to complement use of PDQI-9. Trials of the PDQI-9 at other institutions, of different size, using different EHRs, and incorporating additional physician specialties and notes of other healthcare providers are needed to confirm its generalizability.

SUBMITTER: Stetson PD

PROVIDER: S-EPMC3347480 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Accurate and detailed documentation of surgical procedures is part of good clinical practice, set out by the General Medical Council (GMC). Knee arthroscopy often involves large data sets which require accurate documentation for future assessment and management. This study assesses the quality of documentation of knee arthroscopy, followed by an evaluation of the implementation of a novel operative proforma. A review of 30 consecutive knee arthroscopy operation notes were analysed for missing information, set against a standardised 30 point criteria. An operation proforma was then introduced, and a further 30 consecutive knee arthroscopy operation notes were analysed. We evaluated allied health professional satisfaction with a Likert point scale survey of 21 allied healthcare professionals (recovery and ward nurses, and physiotherapists) following introduction of the proforma. The mean number of missing items on a 30 point scale was 8.8 (range 0 to 23). Examination under anaesthesia was missed in 43% of cases, tourniquet time in 37% of cases, and wear results in 17% of cases. Following introduction of the proforma, the mean number of missing items was 1.1 (range 0 to 24; p <0.001). This rose to 3.8 after one year (p <0.001) before improvement to 0.7 (p <0.01) with a new and improved proforma. Eighty percent strongly agreed the operation note was clearer, 90% strongly agreed it was more legible, 90% strongly agreed it was more understandable, 50% strongly agreed there was more information recorded, and 100% strongly agreed on the proforma having been improved. Knee arthroscopy is a common procedure with large data sets, which can often be missed or incomplete. A standardised proforma results in a statistically significant improvement in documentation and reduces the incidence of missing information. They are subjectively clearer, more legible, and generally better compared with handwritten notes. This study demonstrates the improvements in healthcare documentation, both clinically and legally, following introduction of a simple proforma. This concept should be applicable to different specialities and procedures in healthcare.

Project description:ObjectiveThe medication process requires clear and transparent documentation in patient records. Incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse events. To comprehensively assess the quality of in-hospital medication documentation, we developed a retrospective chart review (RCR) instrument. We report on the development process, the feasibility of the instrument and describe our application of the instrument to a sample of patient records.DesignCross-sectional study using an RCR instrument to evaluate paper-based, non-standardised prescription and medication administration charts (MediDocQ).SettingTwo German university hospitals.ParticipantsRecords from 1361 patients admitted between April and July 2015 were evaluated.MethodsThe MediDocQ development process comprised six consecutive stages: focused literature review, web-based search, initial patient record screening, review by project advisory board, focus groups with professionals and pilot testing. The final 54-item RCR instrument covers three key components of medication documentation: (1) completeness of documented information (including prescription, medication administration and pro re nata (PRN) medication), (2) quality of transcriptions and (3) compliance with chart structure, legibility, handling of deletions and chart corrections. Descriptive statistics are presented as mean values, SD, median and interquartile ranges for individual items.ResultsOverall, 33 out of 54 items resulted in mean values above 0.75, indicating high-quality medication documentation. Documentation quality was particularly compromised for verbal and PRN orders (which involve more steps than standard orders) and when documentation was not completed at the same time as medication administration.ConclusionsMediDocQ is a patient safety instrument that can be used to evaluate the quality of medication documentation and identify components of the process where intervention is required. In our setting, standardisation of medication documentation, particularly regarding medication administration and PRN medication is a priority.

Project description:BackgroundOptimization of the electronic medical record (EMR) is essential to support the clinician and to improve the quality and efficiency of patient care. The present report describes the development and implementation of a standardized template that is embedded in the EMR and is focused on a comprehensive physical examination during the evaluation of pediatric supracondylar humeral fractures. We compared the completeness of physical examinations as well as the timing of detection and documentation of neurovascular injuries before and after implementation of the template. We hypothesized that the use of a template would increase the completeness of examinations and would lead to earlier documentation of neurovascular injuries.MethodsA multidisciplinary quality-improvement task force was created to address neurovascular documentation practices for patients who underwent operative treatment of supracondylar humeral fractures. Following a series of formative and process evaluations, a standardized EMR template was implemented. Neurovascular examination documentation practices that were in use before (pre-template group, n = 224) and after (template group, n = 300) the implementation of the template were compared. Logistic regression analyses of the 2 groups were used to compare the likelihood of a complete neurovascular examination and the timing of neurovascular injury identification.ResultsThere was significant improvement in the documentation of the vascular (odds ratio [OR], 70.7; 95% confidence interval [CI], 39.5 to 126.6; p < 0.0001), motor (OR, 17.6; 95% CI, 9.5 to 32.7; p < 0.0001), and sensory (OR, 23.9; 95% CI, 12.9 to 44.4; p < 0.0001) examinations in the template group. Neurological injuries were more likely to be identified preoperatively in the template group compared with the pre-template group (OR, 6.8; 95% CI, 1.7 to 27.1; p = 0.0067).ConclusionsThe incorporation of a standardized template in the EMR improved the completeness and timing of documentation of neurological injury. Standardized EMR templates developed by a clinically driven multidisciplinary task force have the potential to improve the quality of clinical documentation and to ease communication among providers.Level of evidenceLevel III. See Instructions for Authors for a complete description of levels of evidence.

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Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9).

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