Preliminary Development of the Physician Documentation Quality Instrument

• DOI: 10.1197/jamia.m2404
• Publication Date: 2008-06-30T14:17:53Z
• Authors: P. D. Stetson; F. P. Morrison; S. Bakken; S. B. Johnson
• Keywords: Medical Records Systems, Computerized; Quality Assurance, Health Care; Physicians; 0202 electrical engineering, electronic engineering, information engineering; Documentation; 02 engineering and technology; Factor Analysis, Statistical; 3. Good health

This study sought to design and validate a reliable instrument assess the quality of physician documentation.Adjectives describing clinician attitudes about high-quality clinical documentation were gathered through literature review, assessed by experts, transformed into semantic differential scale. Using scale, physicians nurse practitioners scored importance adjectives for in three note types: admission, progress, discharge notes. Psychometric methods including exploratory factor analysis applied provide preliminary evidence construct validity internal consistency reliability.A 22-item Physician Documentation Quality Instrument (PDQI) was developed. Exploratory (n = 67 respondents) on types resulted solutions ranging from four (discharge) six (admission progress) factors, explained 65.8% 73% variance. Each solution unique. However, sets items consistently factored together across all (1) up-to-date current; (2) brief, concise, succinct; (3) organized structured; (4) correct, comprehensible, consistent. Internal reliabilities were: admission (factor scales 0.52-88, overall 0.86), progress 0.59-0.84, 0.87), summary 0.76-0.85, 0.88).The analyses reliability PDQI. Two novel dimensions document developed related form (Well-formed, Compact). Additional work is needed intrarater interrater applying proposed examine reproducibility factors other samples.