Promoting Responsible Electronic Documentation: Validity Evidence for a Checklist to Assess Progress Notes in the Electronic Health Record

Bierman, Jennifer A.; Hufmeyer, Kathryn Kinner; Liss, David T.; Weaver, A. Charlotta; Heiman, Heather L.

doi:10.1080/10401334.2017.1303385

Cited by 19 publications

(21 citation statements)

References 22 publications

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“…This should be evaluated for utility in Emergency Medicine in the future, as it appears to have good internal and external validity. We also note publication of a new internal medicine scoring tool [28] in May 2017 but suggest further validation work given its Cohen's kappa of 0.67.…”

Section: Fit With Current Knowledgementioning

confidence: 89%

The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine

Walker¹,

Wang²,

Dunlop³

et al. 2017

Appl Clin Inform

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SummaryBackground: Scribes are assisting Emergency Physicians by writing their electronic clinical notes at the bedside during consultations. They increase physician productivity and improve their working conditions. The quality of Emergency scribe notes is unevaluated and important to determine. Objective: The primary objective of the study was to determine if the quality of Emergency Department scribe notes was equivalent to physician only notes, using the Physician Documentation Quality Instrument, Nine-item tool (PDQI-9). Methods: This was a retrospective, observational study comparing 110 scribed to 110 non-scribed Emergency Physician notes written at Cabrini Emergency Department, Australia. Consultations during a randomised controlled trial of scribe/doctor productivity in 2016 were used. Emergency physicians and nurses rated randomly selected, blinded and de-identified notes, 2 raters per note. Comparisons were made between paired scribed and unscribed notes and between raters of each note. Characteristics of individual raters were examined. The ability of the tool to discriminate between good and poor notes was tested. Results: The PDQI-9 tool has significant issues. Individual items had good internal consistency (Cronbach's alpha=0.93), but there was very poor agreement between raters (Pearson's r=0.07, p=0.270). There were substantial differences in PDQI-9 scores allocated by each rater, with some giving typically lower scores than others, F(25,206)=1.93, p=0.007. The tool was unable to distinguish good from poor notes, F(3,34)=1.15, p=0.342. There was no difference in PDQI-9 score between scribed and non-scribed notes. Conclusions: The PDQI-9 documentation quality tool did not demonstrate reliability or validity in evaluating Emergency Medicine consultation notes. We found no evidence that scribed notes were of poorer quality than non-scribed notes, however Emergency scribe note quality has not yet been determined.

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Section: Fit With Current Knowledgementioning

confidence: 89%

The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine

Walker¹,

Wang²,

Dunlop³

et al. 2017

Appl Clin Inform

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“…A number of measures have been adopted in the training of medical residents to minimize errors related to EMR, including the use of checklists to evaluate the quality of documents and limiting patient load to ensure an optimal learning environment. 9 The core committee of Accreditation Council for Graduate Medical Education (ACGME), the regulating body for graduate medical education ACGME in the United States recommends a team cap of 20 patients for a supervising resident when supervising more than 1 first-year resident and a cap of 10 patients for a first-year resident for ongoing care. 8 A recent study published showed that in US teaching programs, residents spend more time participating in indirect patient care than interacting with patients.…”

Section: Discussionmentioning

confidence: 99%

“…This is a validated scoring system to assess quality and accuracy of physician EMR progress notes and evaluates if notes were updated, succinct, truthful, and accurate in the documentation of symptoms, physical examination, laboratory and imaging investigations, diagnostic assessment, and management plan. 9 As per institutional policy, the study was exempt from institutional review board process being a quality improvement study by educators (Residency Program Director and Chief Residents) without deviation from routine educational practices.…”

Section: Methodsmentioning

confidence: 99%

Impact of Patient Load on the Quality of Electronic Medical Record Documentation

Jacob

Raj

Alagusundaramoorthy

et al. 2021

Journal of Medical Education and Curricular Development

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Objective: American College of Graduate Medical Education (ACGME) recommends ongoing care of 10 patients per resident however its implication is unclear. We hypothesized EMR quality to vary based on patient load and call status. Methods: We conducted a double-blind, single-center, retrospective observational study between 2017 and 2019 to investigate the quality and accuracy of resident documentation using the Responsible Electronic Documentation (RED) Checklist, a validated scoring system. Results: A total of 234 independent charts were analyzed and 80 met scoring criteria. Average patients per residents was 4, 9.1, 7.2, and 5.5 on “call” day (D0), “post-call” day (D1), “mid-call” day (D2), and “pre-call” day (D3), respectively. Mean RED checklist scores were 68.1%, 57%, 68.6%, and 72.1% on the above call status. The difference in score between D3 and D1 was statistically significant ( P = .00042). There was a negative correlation between score and number of patients per resident ( r = −0.286, P = .010). Conclusion: EMR documentation quality is directly impacted by patient load and resident call status with the lowest documentation quality on post-call day, correlating with patient load.

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“…QNOTE assesses outpatient notes, 1, 2 while PDQI-9 assesses inpatient notes. 6,8,13 Both QNOTE and PDQI-9 are based on subjective adjectives as assessment items, such as "concise" or "up-to-date", which do not provide concrete, actionable feedback to learners. PDQI-9 also requires assessors to be familiar with the patient or perform significant chart review.…”

Section: Introductionmentioning

confidence: 99%

Development and Establishment of Initial Validity Evidence for a Novel Tool for Assessing Trainee Admission Notes

et al. 2020

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BACKGROUND: Documentation is a key component of practice, yet few curricula have been published to teach trainees proper note construction. Additionally, a gold standard for assessing note quality does not exist, and no documentation assessment tools integrate with established competency-based frameworks. OBJECTIVE: To develop and establish initial validity evidence for a novel tool that assesses key components of trainee admission notes and maps to the Accreditation Council for Graduate Medical Education (ACGME) milestone framework. DESIGN: Using an iterative, consensus building process we developed the Admission Note Assessment Tool (ANAT). Pilot testing was performed with both the supervising attending and study team raters not involved in care of the patients. The finalized tool was piloted with attendings from other institutions. PARTICIPANTS: Local experts participated in tool development and pilot testing. Additional attending physicians participated in pilot testing. MAIN MEASURES: Content, response process, and internal structure validity evidence was gathered using Messick's framework. Inter-rater reliability was assessed using percent agreement. KEY RESULTS: The final tool consists of 16 checklist items and two global assessment items. Pilot testing demonstrated rater agreement of 72% to 100% for checklist items and 63% to 70% for global assessment items. Note assessment required an average of 12.3 min (SD 3.7). The study generated validity evidence in the domains of content, response process, and internal structure for use of the tool in rating admission notes. CONCLUSIONS: The ANAT assesses individual components of a note, incorporates billing criteria, targets note "bloat," allows for narrative feedback, and provides global assessments mapped to the ACGME milestone framework. The ANAT can be used to assess admission notes by any attending and at any time after note completion with minimal rater training. The ANAT allows programs to implement routine note assessment for multiple functions with the use of a single tool.

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Promoting Responsible Electronic Documentation: Validity Evidence for a Checklist to Assess Progress Notes in the Electronic Health Record

Cited by 19 publications

References 22 publications

The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine

The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine

Impact of Patient Load on the Quality of Electronic Medical Record Documentation

Development and Establishment of Initial Validity Evidence for a Novel Tool for Assessing Trainee Admission Notes

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