Login Register Cart 0
Generic placeholder image

Current Diabetes Reviews

Editor-in-Chief

ISSN (Print): 1573-3998
ISSN (Online): 1875-6417

Back
Journal Home About Journal Editorial Board Journal Insight Current Issue Volumes/Issues
Subscribe
Research Article

Quantitative Evaluation of Diabetic Medical Record Documentation

Author(s): Zahra Mazloum Khorasani, Mahmood Tara, Zahra Ebnehoseini*, Kobra Etminani and Zohreh Moosavi

Volume 15, Issue 2, 2019

Page: [158 - 163] Pages: 6

DOI: 10.2174/1573399814666180622161309

Price: $65

Abstract

Background: The documentation of medical records of diabetic patients is very important for the treatment of diabetes. The purpose of this study was to conduct quantitative evaluations of the Diabetic Medical Record (DMR) and Documentation Completeness Rate (DCR).

Methods: In this retrospective study, we evaluated the DCR of DMRs in the Comprehensive Diabetes Center of Imam Reza Hospital (CDRIRH). A checklist was prepared to evaluate the DCR. The overall assessment of the DCR was represented according to the following rating: 95–100% as strong, 75–94% as moderate, and less than 75% as weak. The free texts that physicians recorded in the DMRs were extracted to identify the data elements that physicians must record. In addition, the clinical importance of the data elements of the DMRs from the perspective of the endocrinologists was determined and then compared with the DCR.

Results: In this study, 1,200 DMRs and DCRs for 50 data elements in eight major categories were evaluated. The total DCR average was 30% and data elements in the laboratory test results category demonstrated the highest DCR (50.5%), whereas the least percentage was demonstrated in the internal visits category. The DCR for the other main categories was: demographic information = 48.5%; patient referral 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 of the free text data element in the DMRs indicated that physicians documented free text data elements in three categories.

Conclusion: Our results demonstrated a weak level of documentation in the DMRs. The physicians had written many data elements in the margins of the DMRs. Therefore, it indicates the necessity to modify and change the structure of the DMR.

Keywords: Diabetes mellitus, type 1, type 2, medical records, documentation, medical records, problem-oriented.

[1]
Aligolbandi K, Bala Ghafari A, Siamian H, Vahedi M, Rashida S. Documentation of diabetic patients records at the educational hospitals of Sari, Iran. J Mazandaran Univ Med Sci 2010; 20(76): 70-6.
[2]
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27(5): 1047-53.
[3]
Coppell KJ, Anderson K, Williams SM, Lamb C, Farmer VL, Mann JI. The quality of diabetes care: A comparison between patients enrolled and not enrolled on a regional diabetes register. Prim Care Diabetes 2011; 5(2): 131-7.
[4]
Annersten Gershater M, Pilhammar E, Alm Roijer C. Documentation of diabetes care in home nursing service in a Swedish municipality: A cross‐sectional study on nurses’ documentation. Scand J Caring Sci 2011; 25(2): 220-6.
[5]
Wigert H, Wikström E. Organizing person-centred care in paediatric diabetes: Multidisciplinary teams, long-term relationships and adequate documentation. BMC Res Notes 2014; 7(1): 72.
[6]
International Organization for Standardization (ISO), Business requirements for health summary records-Part 1: Requirements and Part 2 ISO TC 215/SC/WG8 N 606). 2008; p 15.
[7]
Scott D, Hallett C, Fettiplace R. Data-to-text summarisation of patient records: Using computer-generated summaries to access patient histories. Patient Educ Couns 2013; 92(2): 153-9.
[8]
Lobo SE, Rucker J, Kerr M, Gallo F, Constable G, Hotopf M, et al. A comparison of mental state examination documentation by junior clinicians in electronic health records before and after the introduction of a semi-structured assessment template (OPCRIT+). Int J Med Inform 2015; 84(9): 675-82.
[9]
Almidani E, Hussain IB, Almofada S, Hijazi M, Almalhooq N, Alobari R, et al. The effect of implementing a standardized process on the quality of discharge summaries. Int J Pediatr Adolesc Med 2014; 1(2): 78-88.
[10]
Mahmoudian S, Alidadi F, Arji G, Ramezani A. Evaluation of completeness and legal aspects’compliance of emergency’s medical records in teaching hospitals of Zabol university of medical sciences. JPSR 2014; 3(1): 33-9.
[11]
Saravi BM, Asgari Z, Siamian H, et al. Documentation of medical records in hospitals of Mazandaran university of medical sciences in 2014: A quantitative study. Acta Inform Med 2016; 24(3): 202.
[12]
Asghari Z, Mardanshahi A, Farahabadi EB, et al. The quantitative study of the faculty members performance in documentation of the medical records in teaching hospitals of Mazandaran university of medical sciences. Mater Sociomed 2016; 28(4): 292.
[13]
An Independent Licensee of the Blue Cross and Blue Shield Association. Correctly Coding: diabetes mellitus.2. [Cited at 2017 April 10]. Available from: https://www.bcbsal.org/PROVIDERS/ pdfs/CPOH_CodingDiabetes.pdf Accessed.
[14]
Mashoufi M, Rostami K, Mardi A. Documentation of medical records by physicians in the hospitals under Ardabil University of Medical Sciences, 2001. J Ardabil Univ Med Sci 2006; 6(1): 73-7.
[15]
Shafiee G, Mohajeri-Tehrani M, Pajouhi M, Larijani B. The importance of hypoglycemia in diabetic patients. J Diabetes Metab Disord 2012; 11(1): 17.
[16]
Jonnagaddala J, Liaw S-T, Ray P, Kumar M, Dai H-J, Hsu C-Y. Identification and progression of heart disease risk factors in diabetic patients from longitudinal electronic health records Biomed Res Int. 2015; 2015.
[17]
Gross JL, De Azevedo MJ, Silveiro SP, Canani LH, Caramori ML, Zelmanovitz T. Diabetic nephropathy: diagnosis, prevention, and treatment. Diabetes Care 2005; 28(1): 164-76.
[18]
Schreiber AK, Nones CF, Reis RC, Chichorro JG, Cunha JM. Diabetic neuropathic pain: Physiopathology and treatment. World J Diabetes 2015; 6(3): 432.
[19]
D.M Nathan, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329(14): 977-86.
[20]
American Diabetes Association [Internet]. America, 2017. [Cited at 2017 April 10]. Available from:. http://www.diabetes.org/living-with-diabetes/complications

Rights & Permissions Print Cite
Article Metrics
28
2
© 2024 Bentham Science Publishers | Privacy Policy