Literature DB >> 28956888

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

Katherine J Walker1, Andrew Wang, William Dunlop, Hamish Rodda, Michael Ben-Meir, Margaret Staples.   

Abstract

BACKGROUND: 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.

Keywords:  Clinical Documentation and Communications; Emergency Medicine; Quality; Safety Culture; Scribe

Mesh:

Year:  2017        PMID: 28956888      PMCID: PMC6220701          DOI: 10.4338/ACI2017050080

Source DB:  PubMed          Journal:  Appl Clin Inform        ISSN: 1869-0327            Impact factor:   2.342


  20 in total

1.  The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency.

Authors:  George J Kargul; Scott M Wright; Amy M Knight; Mary T McNichol; Jeffrey M Riggio
Journal:  Am J Med Qual       Date:  2012-06-08       Impact factor: 1.852

2.  Impact of scribes on performance indicators in the emergency department.

Authors:  Rajiv Arya; Danielle M Salovich; Pamela Ohman-Strickland; Mark A Merlin
Journal:  Acad Emerg Med       Date:  2010-05       Impact factor: 3.451

3.  Preliminary development of the physician documentation quality instrument.

Authors:  Peter D Stetson; Frances P Morrison; Suzanne Bakken; Stephen B Johnson
Journal:  J Am Med Inform Assoc       Date:  2008-04-24       Impact factor: 4.497

4.  An ED scribe program is able to improve throughput time and patient satisfaction.

Authors:  Aveh Bastani; Blerina Shaqiri; Kristen Palomba; Dominic Bananno; William Anderson
Journal:  Am J Emerg Med       Date:  2014-03-15       Impact factor: 2.469

5.  Scribes in an ambulatory urology practice: patient and physician satisfaction.

Authors:  Simi Koshy; Paul J Feustel; Michael Hong; Barry A Kogan
Journal:  J Urol       Date:  2010-05-16       Impact factor: 7.450

6.  An electronic documentation system improves the quality of admission notes: a randomized trial.

Authors:  Trevor Jamieson; Jonathan Ailon; Vince Chien; Ophyr Mourad
Journal:  J Am Med Inform Assoc       Date:  2016-06-06       Impact factor: 4.497

7.  Recognizing the Characteristics of Quality Documentation.

Authors:  Tammy Combs
Journal:  J AHIMA       Date:  2016-05

Review 8.  Medical scribes: How do their notes stack up?

Authors:  Anita D Misra-Hebert; Linda Amah; Andrew Rabovsky; Shannon Morrison; Marven Cantave; Bo Hu; Christine A Sinsky; Michael B Rothberg
Journal:  J Fam Pract       Date:  2016-03       Impact factor: 0.493

9.  Annual impact of scribes on physician productivity and revenue in a cardiology clinic.

Authors:  Alan J Bank; Ryan M Gage
Journal:  Clinicoecon Outcomes Res       Date:  2015-09-30

10.  Scribe Impacts on Provider Experience, Operations, and Teaching in an Academic Emergency Medicine Practice.

Authors:  Jeremy J Hess; Joshua Wallenstein; Jeremy D Ackerman; Murtaza Akhter; Douglas Ander; Matthew T Keadey; James P Capes
Journal:  West J Emerg Med       Date:  2015-10-20
View more
  8 in total

1.  Electronic Health Record Documentation Patterns of Recorded Primary Care Visits Focused on Complex Communication: A Qualitative Study.

Authors:  Laura Prater; Anthony Sanchez; Gabriella Modan; Jennifer Burgess; Kim Frier; Nathan Richards; Seuli Bose-Brill
Journal:  Appl Clin Inform       Date:  2019-04-10       Impact factor: 2.342

2.  Characterization of Electronic Health Record Documentation Shortcuts: Does the use of dotphrases increase efficiency in the Emergency Department?

Authors:  Rimma Perotte; Christina Hajicharalambous; Gregory Sugalski; Joseph P Underwood
Journal:  AMIA Annu Symp Proc       Date:  2022-02-21

3.  Chart Completion Time of Attending Physicians While Using Medical Scribes.

Authors:  Sarah T Florig; Sky Corby; Nicholas T Rosson; Tanuj Devara; Nicole G Weiskopf; Jeffrey A Gold; Vishnu Mohan
Journal:  AMIA Annu Symp Proc       Date:  2022-02-21

4.  Comparing Scribed and Non-scribed Outpatient Progress Notes.

Authors:  Adam Rule; Sarah T Florig; Steven Bedrick; Vishnu Mohan; Jeffrey A Gold; Michelle R Hribar
Journal:  AMIA Annu Symp Proc       Date:  2022-02-21

5.  The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.

Authors:  Tom Ebbers; Rudolf B Kool; Ludi E Smeele; Richard Dirven; Chrisje A den Besten; Luc H E Karssemakers; Tim Verhoeven; Jasmijn M Herruer; Guido B van den Broek; Robert P Takes
Journal:  J Med Syst       Date:  2022-05-27       Impact factor: 4.920

6.  The Evidence Base for Scribes and the Disruptions of COVID-19.

Authors:  Katie Walker; Heather A Heaton
Journal:  Ann Emerg Med       Date:  2020-09-21       Impact factor: 5.721

7.  Quality Improvement: Effect of Standardized Plastic Surgery Consultation Note Templates on Charge Capture.

Authors:  Christine V Schaeffer; Rachel Park; Jaina Lane; Brent R DeGeorge
Journal:  Plast Reconstr Surg Glob Open       Date:  2021-09-22

8.  Impact of scribes on emergency medicine doctors' productivity and patient throughput: multicentre randomised trial.

Authors:  Katherine Walker; Michael Ben-Meir; William Dunlop; Rachel Rosler; Adam West; Gabrielle O'Connor; Thomas Chan; Diana Badcock; Mark Putland; Kim Hansen; Carmel Crock; Danny Liew; David Taylor; Margaret Staples
Journal:  BMJ       Date:  2019-01-30
  8 in total

北京卡尤迪生物科技股份有限公司 © 2022-2023.