Quantitative Evaluation of Diabetic Medical Record Documentation

The documentation of medical records of diabetic patients is very important for the treatment of diabetes. The purpose of this study was to conduct quantitative evaluations of the Diabetic Medical Record (DMR) and Documentation Completeness Rate (DCR).

In this retrospective study, we evaluated the DCR of DMRs in the Comprehensive Diabetes Center of Imam Reza Hospital (CDRIRH). A checklist was prepared to evaluate the DCR. The overall assessment of the DCR was represented according to the following rating: 95-100% as strong, 75-94% as moderate, and less than 75% as weak. The free texts that physicians recorded in the DMRs were extracted to identify the data elements that physicians must record. In addition, the clinical importance of the data elements of the DMRs from the perspective of the endocrinologists was determined and then compared with the DCR.

In this study, 1,200 DMRs and DCRs for 50 data elements in eight major categories were evaluated. The total DCR average was 30% and data elements in the laboratory test results category demonstrated the highest DCR (50.5%), whereas the least percentage was demonstrated in the internal visits category. The DCR for the other main categories was: demographic information = 48.5%; patient referral information = 14.2%; diagnosis = 5%; anti-hyperglycemic medications = 25.5%; diabetic complications = 17.7%; and results of specialty and subspecialty consultation = 41.7%. The evaluation of the free text data element in the DMRs indicated that physicians documented free text data elements in three categories.

Our results demonstrated a weak level of documentation in the DMRs. The physicians had written many data elements in the margins of the DMRs. Therefore, it indicates the necessity to modify and change the structure of the DMR.