Design and implementation of tools for rapid assessment of the status of documentation of emergency department' physicians

A. Mousavi, M. Yousefi, Jamshid Jamali, M. Meraji, S. Fazaeli
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Abstract

Aim: Medical record documentation by physicians in the emergency department is very important because it determines the required services of patients in the next step. This study aimed to design and implement appropriate tools for the rapid assessment of physicians' documentation in the emergency department. Methods: The present study was a cross-sectional study. First, a comprehensive review of resources was done in Google Scholar, PubMed, Web of Science, Scopus, Iran doc, and SID until 2021. Physician documentation indicators were provided to health information management specialists, emergency medicine specialists, forensic specialists, and the head of the HIM department in hospitals. Intra-class correlation coefficient (ICC) was used to evaluate face and content validity for instrument reliability. Then, the proposed tool randomly selected and reviewed 230 medical records of Imam Reza (AS) Hospital in Mashhad. Data were analyzed using SPSS 21 software. Results: First, a tool with 26 indicators was developed. Intra-class correlation coefficient (ICC) was obtained from the test of 30 medical records 0.980, which was acceptable. Seventeen indicators had scores higher than 0.79, 0.714, and 3.55 and CVR and face validity, including signature, date and time, diagnoses and procedures, correction of errors. The assessment results of 230 medical records showed a relatively good state of documentation of emergency physicians. Conclusion: The proposed tool allows the rapid assessments of the key index in the documentation of physicians in the emergency department and has high validity and reliability, so it is recommended to be used in the emergency department.
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设计和实施快速评估急诊科医生文件状态的工具
目的:急诊科医生的病历文件非常重要,因为它决定了下一步患者需要的服务。本研究旨在设计和实施适当的工具,以快速评估急诊科医生的文件。方法:本研究为横断面研究。首先,在2021年之前,对Google Scholar、PubMed、Web of Science、Scopus、Iran doc和SID等资源进行了全面的审查。向卫生信息管理专家、急诊医学专家、法医专家和医院卫生保健部门负责人提供了医生文件指标。类内相关系数(ICC)用于评估仪器信度的面效度和内容效度。然后,拟议的工具随机选择并审查了马什哈德伊玛目礼萨医院的230份医疗记录。数据分析采用SPSS 21软件。结果:首先,开发了一个包含26个指标的工具。对30份病案进行检验,类内相关系数(ICC)为0.980,可以接受。签名、日期和时间、诊断和程序、错误纠正等17项指标得分高于0.79、0.714和3.55,CVR和面效度高于3.55。230份病历的评估结果显示,急诊医生的档案状况相对较好。结论:该工具可快速评估急诊科医师文献中的关键指标,具有较高的效度和信度,推荐在急诊科使用。
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