Design and implementation of tools for rapid assessment of the status of documentation of emergency department' physicians

Medical record documentation by physicians in the emergency department is very important because it determines the required services of patients in the next step. This study aimed to design and implement appropriate tools for the rapid assessment of physicians' documentation in the emergency department.

The present study was a cross-sectional study. First, a comprehensive review of resources was done in Google Scholar, PubMed, Web of Science, Scopus, Iran doc, and SID until 2021. Physician documentation indicators were provided to health information management specialists, emergency medicine specialists, forensic specialists, and the head of the HIM department in hospitals. Intra-class correlation coefficient (ICC) was used to evaluate face and content validity for instrument reliability. Then, the proposed tool randomly selected and reviewed 230 medical records of Imam Reza (AS) Hospital in Mashhad. Data were analyzed using SPSS 21 software.

First, a tool with 26 indicators was developed. Intra-class correlation coefficient (ICC) was obtained from the test of 30 medical records 0.980, which was acceptable. Seventeen indicators had scores higher than 0.79, 0.714, and 3.55 and CVR and face validity, including signature, date and time, diagnoses and procedures, correction of errors. The assessment results of 230 medical records showed a relatively good state of documentation of emergency physicians.

The proposed tool allows the rapid assessments of the key index in the documentation of physicians in the emergency department and has high validity and reliability, so it is recommended to be used in the emergency department.