A generic method to monitor completeness and speed of medical documentation processes.

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 i...

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Publicado en:Methods of Information in Medicine Vol. 51; no. 2; pp. 252 - 258
Autores principales: Dugas M, Dugas-Breit S, Dugas, M, Dugas-Breit, S
Formato: research Journal Article
Publicado: Thieme Medical Publishing Inc. 2012
Acceso en línea:Ver este registro en EBSCOhost
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        atl: A generic method to monitor completeness and speed of medical documentation processes.
      aug:
        au:
          Dugas M
          Dugas-Breit S
          Dugas, M
          Dugas-Breit, S
        affil: Institute of Medical Informatics, University of Münster, Domagkstr. 9, 48149 Münster, Germany
      sug:
        subj:
          Documentation Methods
          Organizational Efficiency
          Patient Record Systems Equipment and Supplies
          Productivity
          Human
          Medical Informatics
          Patient Discharge
          Quality of Health Care
          Statistics
          Task Performance and Analysis
          Time
      ab: 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.
      pubtype: Academic Journal
      doctype:
        research
        Journal Article
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    language: English
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