[Content validity of an information system used for head injury rehabilitation based on an analysis of medical records]. / Validation par les dossiers médicaux d'un système d'informationdédié à la clientèle victime d'un traumatisme crânien.

ABSTRACT

OBJECTIVE: This study examines the content validity of the TCC-Québec Information System based on an analysis of rehabilitation medical records. The goal was to determine the agreement between the variables of the TCC-Québec Information System identified by experts and based on an extensive literature review and those found in medical records. METHOD: The medical records of 82 adults with a head injury were reviewed. The individuals had been hospitalized from 1997 to 1998 at three different acute care facilities or three rehabilitation centers. The abstractor determined if the information pertaining to a variable (e.g. personal history, impairments, or disabilities relating to sensori-motor function) was present in the record. A standardized and reliable procedure was used to ensure the quality of data extraction. The percentage of variables found in the medical records and the number of records in which each variable was documented were calculated for each clinical setting (acute care or rehabilitation) and for the different geographical regions. RESULTS: The results suggest that a large discrepancy exists between what experts desired to be included in the information system and what is really documented clinically. No discrepancy exists between the different regions. Only 23% of variables were found in more than 70% of records. CONCLUSION: This study provides recommendations about the most relevant variables to be included in an information system based on clinicians'information needs and the clinical reality. As such, these results should facilitate the use and implementation of the information system under study.