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DOI: 10.3414/ME09-01-0085
A Generic Method to Monitor Completeness and Speed of Medical Documentation Processes[*]
Publication History
received:28 September 2009
accepted:20 February 2011
Publication Date:
20 January 2018 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00035037/201203/lookinside/thumbnails/10-3414-me-09-01-0085-1.jpg)
Summary
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.
Keywords
Medical documentation process - completeness - electronic dictation system - CRF - clinical trial documentation* Supplementary material published on our website www.methods-online.com
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