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A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and
Cecilia Veraar1, Paul Hasler2, Michael Schirmer1
1Department of Internal Medicine, Clinic II, Medizinische Universität Innsbruck, Innsbruck, Austria.
Health Services Research and Managerial Epidemiology
|February 17, 2018
Summary
A consensus checklist was developed to guide the creation of structured clinical documentation tools for patient care and research. This standardized approach ensures high-quality data for electronic health records and registries.
Area of Science:
- Medical Informatics
- Health Services Research
- Clinical Documentation
Background:
- A strategic approach for structured clinical documentation tools for patient care and research is currently lacking.
- Electronic health records are becoming increasingly structured and detailed.
Purpose of the Study:
- To achieve interdisciplinary consensus on a checklist for developing disease- and situation-specific clinical documentation tools.
Main Methods:
- A two-round Delphi consensus process involving 19 physicians and 14 students from Austria, Switzerland, and Germany.
- Agreement was defined as 80% or more positive participant votes.
Main Results:
- High agreement (97%) was reached on establishing a working group for developing structured documentation tools.
- A final checklist included 4 recommendations for working group setup, 12 for content, and 3 general/technical recommendations (mean agreement 97.4%).
Conclusions:
- Structured, disease- and situation-specific documentation tools will bridge electronic health records and registries.
- Checklist-defined tools will yield quality data for registries and clinical care.
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