Assessing the status of tools and methods for evaluating physicians' documentation in the emergency department: A review study
andAbstract
Introduction: Documentation of medical records is the first and most important source of patient information collection. On the other hand, the correct registration of medical records is considered as one of the criteria of physicians' scientific skills. Therefore, the purpose of this study was a systematic review to examine the status of tools and methods for evaluating the documentation of physicians in the emergency department.
Material and Methods: This systematic review was performed in studies related to the evaluation of the documentation status of emergency department physicians. The studies were available from PubMed, Web of Science, Scopus, Irandoc and SID databases by the end of 2020. Titles and abstracts were reviewed independently based on eligibility criteria. After that, the complete texts were retrieved and independently reviewed by two researchers based on eligibility criteria. A standardized form was used to extract the data including study title, first author name, years of study, place of study, number of samples, research method, tools, indicators studied and main findings.
Results: A total of 4693 related studies were extracted from the database and finally 40 main articles were included in the study. In 4 cases, the level of documentation was reported to be incomplete and undesirable by examining the registered files; In the other 4 cases, they estimated the amount of documentation as moderate to favorable. In 2 cases, the effect of education and in 2 cases, the effect of feedback and encouragement on documentation were measured. None of the studies provided a comprehensive tool for evaluating physicians' documentation of emergencies; Evaluation patterns were different in each study and were partially reviewed.
Conclusion: A review of research conducted in Iran and the world on documenting physicians, especially in the emergency department, emphasizes the importance of continuing the process of patients. Consequently, the consequences are the same for all stakeholders in the medical record. In addition, the effect of feedback and encouragement was more effective than training in improving documentation, so it is suggested that programs be applied for ongoing feedback to documentarians.
INTRODUCTION
Documentation of medical records is the first and most important source of data collection for patients [1]. On the other hand, proper recording of medical records is considered as one of the criteria of physicians 'scientific skills. Improving physicians' documentation behavior by designing targeted interventions including training, auditing and feedback, continuing education and reminders seems necessary. It can also be said that documenting physicians 'records is clearly an essential aspect of physicians' behavior and competency assessment, and its evaluation and improvement has always been emphasized [2].
In the meantime, the emergency department is one of the most important concerns in the field of health, which to improve its status, the existence of proper management and planning and evaluation of emergency activities is very important and one of the effective steps in this field [3].
In emergency patients, the quality of evidence-based and information-based treatment can be a determining factor for life or death or disability during a person's lifetime [4]. Emergency departments (EDs) are fraught with the dangers of poor documentation and the urgent need for accurate records, with frequent changes of staff, high activity levels, overcrowding, frequent interruptions, time pressures, unidentified patient entry patterns, and a wide range of items provided in such environments. Has complete patient care [5].
The work environment of an emergency department (ED) is a unique, complex, and dynamic environment. Errors and allegations of abuse. On the other hand, studies have shown that emergency departments have the most preventable errors [6].
Given that is important that proper documentation makes the medical record a primary tool for evaluating health care practices and care, hospitals should seek to identify the factors that increase the quality of documentation to improve the quality of health care [1]. In order to make evidence-based decisions in this field, there is an appropriate tool to evaluate the documentation of emergency physicians and then implement this tool to examine the status of documentation of emergency physicians to achieve the strengths and weaknesses of documentation and provide appropriate solutions to improve the documentation of emergency physicians. Therefore, the purpose of this study was a systematic review to examine the status of tools and methods for evaluating the documentation of physicians in the emergency department.
MATERIAL AND METHODS
This systematic review was performed on studies related to the evaluation of documentation by emergency physicians. The studies were available from PubMed, Web of Science, Scopus, Irandoc and SID databases by the end of 2020.
Titles and abstracts were reviewed independently based on eligibility criteria. The two researchers independently reviewed the selected articles for the full text and extracted the data in the same form. Form data includes (article title, first author, year and place of study, number of samples, research method, tools, indicators and main findings). Any differences between the extracted data will be resolved through discussion and consensus between the parties, and in case of disagreement, the third author will give a final opinion for review. The questions to be researched are as follows:
1. Is there a standard tool for documenting physicians in the emergency department?
2. What is the documentation status of doctors in the emergency department?
3. What are the effective factors in documenting physicians?
Search strategy
A systematic review of Persian and English studies by searching for related keywords in Mesh and Emtree, including three keyword combinations with AND in keywords, title and abstract of studies in the authoritative scientific databases PubMed, Web of Science, Scopus, Irandoc and SID was explored. Table 1 shows the keywords.
Table 1
Selected Keywords
Selection of studies
A total of 4693 related studies were extracted from the database. 1999 Article was deleted as a duplicate. After reviewing the titles, abstracts and articles, 3226 articles that did not meet the purpose of the study were excluded; and after reviewing 80 main articles, finally 40 main articles were included in the study. Fig 1 showed Preferred Reporting Item for Systematic Reviews (PRISMA) workflow diagram to select articles.
Data extraction
The two researchers independently reviewed the selected articles for the full text and extracted the data in the same form. Form data includes (article title, first author, year and place of study, number of samples, research method, tools, indicators and main findings). Any differences between the extracted data will be resolved through discussion and consensus between the parties, and in case of disagreement, the third author will give a final opinion for review.
RESULTS
A total of 40 studies (21 Persian studies and 19 English studies) related to the tools and methods of evaluating physicians' documentation were included in our study. In 4 cases, by examining the registered files, they reported the level of documentation as incomplete and undesirable [7]. And in 4 other cases, they estimated the amount of documentation as moderate to desirable [3, 8-10]. In 2 of the studies, the effect of education [8] and in 2 cases, the effect of feedback and encouragement on documentation were measured [2, 11]. None of the studies provided a comprehensive tool for evaluating physicians' documentation of emergencies. Evaluation patterns in each study were different and partial. The data extraction results of the studies are as follows (Table 2 and 3):
Table 2
Summary Findings of Reviewing Previous Related Articles (Persian Studies)
Table 3
Summary of Review Findings of Previous Related Articles (English Studies)
DISCUSSION
Documentation of the case by physicians is very important because it determines the services required by the patient in the next service [8]. Therefore, the purpose of this study was a systematic review to examine the documentation of physicians in the emergency department. The results of our systematic review showed that although in 19 cases the studies provided indicators to examine the status of documentation, but some qualitative items, some quantitatively sometimes only one indicator was examined individually. This heterogeneity leads to rework, lack of Comprehensive review and correct decision making in policies and planning [7, 8, 10, 13-15, 17, 18, 23, 24, 26, 28, 31-35, 38, 39].
Since the correct recording of medical records is considered as one of the criteria of physicians' scientific skills, it seems necessary to improve the documentation behavior of physicians by designing targeted interventions including training, encouragement and feedback, continuing education and reminders [2, 8, 17, 30]. A review of research conducted in Iran and the world on the documentation of physicians, especially in the emergency department, emphasizes the importance of continuing the process of patients. In most studies, the amount of documentation was reported incompletely and undesirably [7-10].
Some of the causes of documentation deficiencies were lack of attitude and lack of awareness. However, in the study of Farzandipour et al., Who measured the effect of education on the quality of documentation, there was no significant difference in improving documentation [8]. At the same time, in studies that measured the impact of feedback and encouragement on the improvement of documentation, the results showed an improvement in the documentation process [2, 30]. Therefore, considering scores for physicians who have better documentation than training seems to have a better effect on improving documentation. In some studies, the results showed that computerized recording of medical prescriptions by documentarians had an effective role on the quality of documentation [23, 26, 28, 36].
In line with the results of this study, Salmanizadeh et al. The study showed that 70.34% of the selected files were incomplete for each patient. In most medical records forms, data elements related to the ward secretary were incomplete. In other forms, nurses and physicians did not record more than half of the data elements. The highest number of defects was observed in the forms of electrocardiogram attachment, emergency file and radiographic request, respectively. In addition, data elements such as demographics, initial diagnosis, final diagnosis, and signatures were not completed by the ward secretary, physicians, and nurses [44].
In 2017, Walker et al. showed that physicians’ quality documentation tool does not show reliability in evaluating emergency medical records. No evidence was found of the lower quality of the notes recorded by the documenter than the notes recorded by the emergency physician. Overall, the instrument was unable to diagnose good notes and poor notes [37]. In 2019, Wai-Lee et al. randomly selected 1,200 medical records from patients with abdominal pain, chest pain, shortness of breath, and headache. The 0-10 scoring tool identified five important medical records and physical examinations that should be submitted for each of the four common complaints (abdominal pain, chest pain, shortness of breath, or headache). The maximum score was 10 and the minimum score was 0. The results showed that the year, day and hour presented, patient's age and gender, preferred language, interpreter need, discharge destination and physician's gender were not associated with complete documentation. With interns, registrants and consultants scored significantly lower [44].
CONCLUSION
The results of this study showed that until a comprehensive basis for accurate evaluation of physicians' documentation is developed and used, the process of incorrect documentation continues and has serious consequences for patients, treatment staff and other stakeholders. Although the quality of documentation has been studied in various studies using tools, and some studies have suggested different tools to evaluate its documentation, including case audit checklists, the use of simulators, structured clinical sheets, and these approaches are often evaluated by physicians. These tools do not have high validity and reliability [6, 45-57]. And consequently, the consequences for all stakeholders of the medical record. In addition, the effect of feedback and encouragement from training on improving documentation was greater and better, so it is suggested that programs be applied for ongoing feedback to documentarians.
ACKNOWLEDGMENTS
This study is taken from a part of the dissertation of Master of Health Information Technology approved by the meeting of the Research Council and the meeting of the ethics committee of Mashhad University of Medical Sciences with ethics code 981241, the protocol of which has been approved by the ethics committee of the university with IR.MUMS.REC.1399.34
AUTHOR’S CONTRIBUTION
All authors contributed to the literature review, design, data collection and analysis, drafting the manuscript, read and approved the final manuscript.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest regarding the publication of this study.
FINANCIAL DISCLOSURE
No financial interests related to the material of this manuscript have been declared.