Quantitative Evaluation of Diabetic Medical Record Documentation

摘要

Background: The documentation of medical records of diabetic patients is very importantfor the treatment of diabetes. The purpose of this study was to conduct quantitative evaluations of theDiabetic Medical Record (DMR) and Documentation Completeness Rate (DCR).Methods: In this retrospective study, we evaluated the DCR of DMRs in the Comprehensive DiabetesCenter of Imam Reza Hospital (CDRIRH). A checklist was prepared to evaluate the DCR. The overallassessment of the DCR was represented according to the following rating: 95–100 as strong, 75–94as moderate, and less than 75 as weak. The free texts that physicians recorded in the DMRs were extractedto identify the data elements that physicians must record. In addition, the clinical importance ofthe data elements of the DMRs from the perspective of the endocrinologists was determined and thencompared with the DCR.Results: In this study, 1,200 DMRs and DCRs for 50 data elements in eight major categories wereevaluated. The total DCR average was 30 and data elements in the laboratory test results categorydemonstrated the highest DCR (50.5), whereas the least percentage was demonstrated in the internalvisits category. The DCR for the other main categories was: demographic information = 48.5; patientreferral information = 14.2; diagnosis = 5; anti-hyperglycemic medications = 25.5; diabetic complications= 17.7; and results of specialty and subspecialty consultation = 41.7. The evaluation ofthe free text data element in the DMRs indicated that physicians documented free text data elements inthree categories.Conclusion: Our results demonstrated a weak level of documentation in the DMRs. The physicians hadwritten many data elements in the margins of the DMRs. Therefore, it indicates the necessity to modifyand change the structure of the DMR.