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首页> 外文会议>Medical Informatics Europe Conference >Evaluating Quality of Electronic Clinical Notes Using the Spanish Version of Physician Documentation Quality Instrument (PDQI-9) in a High-Complexity Hospital. Cross-Sectional Study
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Evaluating Quality of Electronic Clinical Notes Using the Spanish Version of Physician Documentation Quality Instrument (PDQI-9) in a High-Complexity Hospital. Cross-Sectional Study

机译：在高度复杂性医院中使用西班牙语版本的医师文档质量仪器（PDQI-9）来评估电子临床笔记的质量。 横断面研究

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Introduction: There are factors inherent in Health Information Systems that, when are used improperly, can degrade the quality of the information, which may imply, among other things, the lack of integrity, inconsistency or inaccuracy of the information. Objective: The aim of this study is to describe the quality of electronic clinical notes using the PDQI-9 score (Spanish version). Methods: We evaluated the judgment on the quality of two medical auditors trained in the use of PDQI-9 tool. The unit of analysis was the 3 types of clinical notes: admission notes, progress notes and discharge summaries of adult patients admitted to general wards. Sampling type: random. Statistical analysis: continuous variables were summarized with median and interquartile range. Medians between 2 reviewers were compared using Mann Whitney hypothesis test. Results: 120 Electronic Health Record (EHR) were selected, the median of the overall quality of the admission notes were 33 (31-34) and 32 (32-37) for each reviewer respectively, without any statistically significant differences (p=0.729). The overall quality of progress notes and discharge summaries were 28 (27-33) vs 27 (27-32), p = 0.175 and 33 (32-34) vs 33 (31-34), p = 0.243, respectively. Conclusions: The quality of the clinical documents evaluated by the trained reviewers using the PDQI-9 score was good. The application of this type of tool is valuable for making a diagnosis in terms of quality that allows improving clinical documentation, as well as peer communication when reading the Electronic Health Record.
机译：简介：健康信息系统中固有的因素是，当使用不当时，可能会降低信息的质量，这些信息可能暗示缺乏完整性，不一致或信息不准确性。目的：本研究的目的是使用PDQI-9分数来描述电子临床笔记的质量（西班牙语版）。方法：我们评估了对使用PDQI-9工具培训的两位医疗审计员质量的判断。分析单位是3种类型的临床票据：入场票据，进展说明和入住普通病房的成年患者的进展说明。抽样类型：随机。统计分析：使用中位数和狭窄的范围总结了连续变量。使用Mann Whitney假设试验进行比较2名审稿人之间的中位数。结果：120个电子健康纪录（EHR）被选中，每次审稿人的入学票据总体质量的中位数分别为33（31-34）和32（32-37），没有任何统计学上显着的差异（P = 0.729 ）。总进步和排放摘要的整体质量分别为28（27-33）vs 27（27-32），p = 0.175和33（32-34），分别为33（31-34），p = 0.243。结论：使用PDQI-9分数评估的临床文件的质量良好。这种类型的工具的应用对于在读取电子健康记录时进行允许改善临床文档的质量和同伴通信的诊断是有价值的。

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