Evaluating Quality of Electronic Clinical Notes Using the Spanish Version of Physician Documentation Quality...

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.

The aim of this study is to describe the quality of electronic clinical notes using the PDQI-9 score (Spanish version).

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.

continuous variables were summarized with median and interquartile range. Medians between 2 reviewers were compared using Mann Whitney hypothesis test.

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.

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.