There is little research on how clinically relevant concepts are transferred from a patient, through a healthcare provider, and then to a resultant clinical note. This study tested whether clinical information flow, defined as the transfer of concepts from patient to note, can be traced. The study's investigators also analyzed the impact of a clinical documentation tool on note content.
Healthcare providers, designated as clinical simulation study subjects, generated clinical notes via two documentation tools. The simulation utilized standardized patient scenario descriptions (PSDs). Independent physician reviewers identified clinical concepts present in the PSDs and in resultant clinic notes. Reviewers identified a total of 256 unique clinical concepts across all PSDs. Of these, a total of 122 unique concepts overlapped for the PSDs and resultant notes from both documentation tools. Additionally, the dictation-based and computer-based notes shared 103 distinct concepts not found in the PSDs.
This study's findings suggest that both computer-based and dictation-based tools are subject to clinical concept loss. Templates may have eased documentation, partly explaining the greater concept count for computer-based notes. This study found that tracing information flow in a clinical simulation encounter is a valid method for evaluating medical documentation tools. Clinical note template availability also likely impacts healthcare provider documentation.
| Identifer | oai:union.ndltd.org:VANDERBILT/oai:VANDERBILTETD:etd-11262012-114245 |
| Date | 10 December 2012 |
| Creators | Khan, Naqi Ali |
| Contributors | Dr. S. Trent Rosenbloom, Dr. Qingxia Chen, Dr. Joshua C. Denny, Dr. Kevin B. Johnson |
| Publisher | VANDERBILT |
| Source Sets | Vanderbilt University Theses |
| Language | English |
| Detected Language | English |
| Type | text |
| Format | application/pdf |
| Source | http://etd.library.vanderbilt.edu/available/etd-11262012-114245/ |
| Rights | restrictsix, I hereby certify that, if appropriate, I have obtained and attached hereto a written permission statement from the owner(s) of each third party copyrighted matter to be included in my thesis, dissertation, or project report, allowing distribution as specified below. I certify that the version I submitted is the same as that approved by my advisory committee. I hereby grant to Vanderbilt University or its agents the non-exclusive license to archive and make accessible, under the conditions specified below, my thesis, dissertation, or project report in whole or in part in all forms of media, now or hereafter known. I retain all other ownership rights to the copyright of the thesis, dissertation or project report. I also retain the right to use in future works (such as articles or books) all or part of this thesis, dissertation, or project report. |
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