Methods Inf Med - A generic method to monitor completeness and speed of medical documentation processes.

Tópicos

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{ record(1888) medic(1808) patient(1693) }
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{ research(1218) medic(880) student(794) }
{ patient(2837) hospit(1953) medic(668) }
{ age(1611) year(1155) adult(843) }
{ signal(2180) analysi(812) frequenc(800) }
{ data(3008) multipl(1320) sourc(1022) }
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{ method(2212) result(1239) propos(1039) }

Resumo

CKGROUND: 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.

Resumo Limpo

ckground physician dedic approxim quarter daili work document complet speed medic document process import paramet can affect qualiti healthcareobject generic method monitor qualiti paramet propos util demonstr two examplesmethod base generic eventdriven process chain medic document process complet function creat final document avail versus requir document time defin quantil process time appli perform indic document speed plot function paramet provid complet speed medic document csmdplot open sourc code sampl data set avail supplementresult methodolog appli analyz effect electron dictat system discharg letter document csmdplot detect signific differ regard speed complet process implement electron dictat addit pinpoint differ regard qualiti paramet document process differ clinic depart second exampl csmdplot use analyz followup document clinic trial due generic design csmdplot can appli medic document process orderentri processesconclus monitor complet speed medic document feasibl can provid quantit inform process

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