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- Title
A Delphi Study Among Internal Medicine Clinicians to Determine Which Therapeutic Information Is Essential to Record in a Medical Record.
- Authors
van Unen, Robert J.; Tichelaar, Jelle; Nanayakkara, Prabath W.B.; van Agtmael, Michiel A.; Richir, Milan C.; de Vries, Theo P.G.M.
- Abstract
Several studies have demonstrated that using a template for recording general and diagnostic information in the medical record (MR) improves the completeness of MR documentation, communication between doctors, and performance of doctors. However, little is known about how therapeutic information should be structured in the MR. The aim of this study was to investigate which specific therapeutic information registrars and consultants in internal medicine consider essential to record in the MR. Therefore, we carried out a 2-round Internet Delphi study. Fifty-nine items were assessed on a 5-pointscale; an item was considered important if ≥80% of the respondents awarded it a score of 4 or 5. In total, 26 registrars and 30 consultants in internal medicine completed both rounds of the study. Overall, they considered it essential to include information about 11 items in the MR. Subgroup analyses revealed that the registrars considered 8 additional items essential, whereas the consultants considered 1 additional item essential to record. Study findings can be used as a starting point to develop a structured section of the MR for therapeutic information for both paper and electronic MRs. This section should contain at least 11 items considered essential by registrars and clinical consultants in internal medicine.
- Subjects
INFORMATION resources; HEALTH; ATTITUDE (Psychology); DELPHI method; HOSPITAL medical staff; INTERNAL medicine; MEDICAL personnel; MEDICAL records; MEDICAL consultants; PSYCHOLOGY
- Publication
Journal of Clinical Pharmacology, 2015, Vol 55, Issue 12, p1415
- ISSN
0091-2700
- Publication type
Article
- DOI
10.1002/jcph.565