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A Generic Method to Monitor Completeness and Speed of Medical Documentation Processes*

Journal: Methods of Information in Medicine
Subtitle: A journal stressing, for more than 50 years, the methodology and scientific fundamentals of organizing, representing and analyzing data, information and knowledge in biomedicine and health care
ISSN: 0026-1270

Focus Theme: Medical Imaging High Performance Methods
Guest Editors: C. Kulikowski, L. Gong

Issue: 2012 (Vol. 51): Issue 3 2012
Pages: 252-257

A Generic Method to Monitor Completeness and Speed of Medical Documentation Processes*

Original Article

Online Supplementary Material

M. Dugas (1), S. Dugas-Breit (2)

(1) Institute of Medical Informatics, University of Muenster, Muenster, Germany; (2) Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universitaet, Munich, Germany


completeness, Medical documentation process, electronic dictation system, CRF, clinical trial documentation


Background: Physicians dedicate approximately a quarter of daily work to documentation. Completeness and speed of medical documentation processes are important parameters, because they can affect quality of healthcare.

Objectives: A generic method to monitor these quality parameters is proposed and its utility is demonstrated in two examples. Methods: Based on a generic event-driven process chain of a medical documentation process, completeness functions for created and finalized documents (available versus required documents by time) are defined. The 95%-quantile of process time is applied as performance indicator of documentation speed. A plotting function for these parameters is provided: completeness and speed of medical documentation (CSMD)-plot. Open source code and a sample data set are available in the Supplement.

Results: This methodology is applied to analyze the effect of an electronic dictation system on discharge letter documents. CSMD-plot detects significant differences regarding speed and completeness of the process before and after implementation of electronic dictation; in addition, it pinpoints differences regarding these quality parameters in documentation processes between different clinical departments. In a second example, CSMD-plot is used to analyze follow-up documentation of a clinical trial. Due to its generic design, CSMD-plots can be applied to other medical documentation processes such as order-entry processes.

Conclusions: Monitoring of completeness and speed of medical documentation is feasible and can provide quantitative information on these processes.

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