A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and Research Purposes:

Health Services Research & Managerial Epidemiology

CeciliaVeraar¹ 

关键词: managerial epidemiology;    managed care;    disease management;    documentation;    clinical;    medical informatics;    health-care research;    health-care records;   

DOI  :  10.1177/2333392817754161

学科分类：医学（综合）

来源: Sage Journals

【 摘 要 】

Background:To the best of our knowledge, a strategic approach to define the contents of structured clinical documentation tools for both clinical routine patient care and research purposes has not been reported so far, although electronic health record will become more and more structured and detailed in the future.Objective:To achieve an interdisciplinary consensus on a checklist to be considered for the preparation of disease- and situation-specific clinical documentation tools.Methods:A 2-round Delphi consensus-based process was conducted both with 19 physicians of different disciplines and 14 students from Austria, Switzerland, and Germany. Agreement was defined as 80% or more positive votes of the participants.Results:The participants agreed that a working group should be set up for the development of structured disease- or situation-specific documentation tools (97% agreement). The final checklist included 4 recommendations concerning the setup of the working group, 12 content-related recommendation...

【 授权许可】

CC BY