Document Detail

A Generic Method to Monitor Completeness and Speed of Medical Documentation Processes.
MedLine Citation:
PMID:  21915436     Owner:  NLM     Status:  Publisher    
Background: Physicians dedicate approximately a quarter of daily work to documentation. Completeness and speed of medical documentation processes are important parameters, because they can affect quality of healthcare. Objectives: A generic method to monitor these quality parameters is proposed and its utility is demonstrated in two examples. Methods: Based on a generic event-driven process chain of a medical documentation process, completeness functions for created and finalized documents (available versus required documents by time) are defined. The 95%-quantile of process time is applied as performance indicator of documentation speed. A plotting function for these parameters is provided: completeness and speed of medical documentation (CSMD)-plot. Open source code and a sample data set are available in the Supplement. Results: This methodology is applied to analyze the effect of an electronic dictation system on discharge letter documents. CSMD-plot detects significant differences regarding speed and completeness of the process before and after implementation of electronic dictation; in addition, it pinpoints differences regarding these quality parameters in documentation processes between different clinical departments. In a second example, CSMD-plot is used to analyze follow-up documentation of a clinical trial. Due to its generic design, CSMD-plots can be applied to other medical documentation processes such as order-entry processes. Conclusions: Monitoring of completeness and speed of medical documentation is feasible and can provide quantitative information on these processes.
M Dugas; S Dugas-Breit
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2011-9-14
Journal Detail:
Title:  Methods of information in medicine     Volume:  50     ISSN:  0026-1270     ISO Abbreviation:  -     Publication Date:  2011 Sep 
Date Detail:
Created Date:  2011-9-14     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0210453     Medline TA:  Methods Inf Med     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Martin Dugas, Univ.-Prof. Dr. med., Dipl.-Inform, Institute of Medical Informatics, University of Münster, Domagkstr. 9, 48149 Münster, Germany.
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