Lost in translation? Information quality in pediatric pre-hospital medical emergencies with a language barrier in Germany.

BACKGROUND: In pediatric medical emergencies, paramedics and emergency physicians must often rely on the information of third parties, often caregivers, to gather information. Failing to obtain relevant information may lead to misinterpretation of symptoms and subsequent errors in decision making and clinical treatment. Thus, children and/or caregivers with limited proficiency of the locally spoken language may be at risk for medical errors. This study analyzes logs of rescue missions to determine whether paramedics could obtain essential information from German-speaking and foreign-language children and their caregivers. METHODS: We conducted a secondary data analysis based on retrospective data on pediatric patients of four emergency medical services (EMS) stations in Northern Germany. We defined language discordance with communication difficulties as main exposure. We used documentation quality as outcome defined as existing information on (a) pre-existing conditions, (b) current medication, and (c) events prior to the medical emergency. Statistical analyses include descriptive statistics, simple regression and multivariable regression. As multivariable regression model, a logistic regression was applied with documentation quality as dependent variable and language discordance with communication difficulties as independent variable adjusted for age, sex and Glasgow Coma Scale (GCS). RESULTS: Data from 1,430 pediatric rescue missions were analyzed with 3.1% (n = 45) having a language discordance with communication difficulties. Patients in the pediatric foreign-language group were younger compared to German-speaking patients. Thorough documentation was more frequent in German-speaking patients than in patients in the foreign-language group. Pre-existing conditions and events prior to the medical emergency were considerably more often documented in German-speaking than for foreign-language patients. Documentation of medication did not differ between these groups. The adjustment of sex, age and GCS in the multivariable analysis did not change the results. CONCLUSION: Language barriers are hindering paramedics to obtain relevant information in pediatric pre-hospital emergencies. This jeopardizes the safe provision of paramedic care to children who themselves or their caregivers are not fluent in German language. Further research should focus on feasible ways to overcome language barriers in pre-hospital emergencies. TRIAL REGISTRATION: This is a retrospective secondary data analysis of a study that was registered at the German Clinical Trials Register (No. DRKS00016719), 08/02/2019.

Documentation quality of patient-directed discharge and early warning interactions in an adult inpatient service.

Documentation quality of patient-physician discussion, assessment, and intervention at the time of patient-directed discharges (elopement and 'against medical advice' discharges) is found to be poor in available studies and, importantly, may be a proxy for quality of care delivered. Less is known about the patient-physician interactions and documentation at the time a patient vocalizes the desire to leave early ('early warning interaction') prior to a patient-directed discharge. This was a cohort study comprising a retrospective chart review of patients leaving 'against medical advice' from an inpatient internal medicine-infectious disease service at a tertiary medical center from 01 July 2020 to 24 September 2021. Documentation quality was assessed using 11 extractable factors detailing patient-physician conversation elements from the assess, investigate, mitigate, explain, and document framework, plus related interventions pertinent to patient safety and care optimization. Descriptive statistics were mainly utilized with inferential statistics and regression models as appropriate. Fifty-two patients left against medical advice and 49 eloped; 11% had an early warning interaction. Aggregate documentation quality scores at early warning interaction (13%), 'against medical advice' discharge (42%), and at elopement (31%) were low. Half of the suggested documentation elements were recorded in no patients. The overall documentation quality was poor, suggesting the need for further training and interventions to facilitate more thorough documentation.

The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.

The reuse of healthcare data for various purposes will become increasingly important in the future. To enable the reuse of clinical data, structured and standardized documentation is conditional. However, the primary purpose of clinical documentation is to support high-quality patient care. Therefore, this study investigated the effect of increased structured and standardized documentation on the quality of notes in the Electronic Health Record. A multicenter, retrospective design was used to assess the difference in note quality between 144 unstructured and 144 structured notes. Independent reviewers measured note quality by scoring the notes with the Qnote instrument. This instrument rates all note elements independently using and results in a grand mean score on a 0-100 scale. The mean quality score for unstructured notes was 64.35 (95% CI 61.30-67.35). Structured and standardized documentation improved the Qnote quality score to 77.2 (95% CI 74.18-80.21), a 12.8 point difference (p < 0.001). Furthermore, results showed that structured notes were significantly longer than unstructured notes. Nevertheless, structured notes were more clear and concise. Structured documentation led to a significant increase in note quality. Moreover, considering the benefits of structured data recording in terms of data reuse, implementing structured and standardized documentation into the EHR is recommended.

[Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings]. / Präferenzen des alltäglichen Lebens in der Pflegedokumentation.

Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings Abstract. Background: In Germany, there was previously no instrument for the systematic recording of preferences for the everyday living of older and people in need of care. Subsequently, in a pilot study, an instrument was translated in a culturally sensitive way (PELI-D), piloted and tested psychometrically. In terms of documentation quality, it is important that the preferences recorded by nursing staff are written down in the nursing record using PELI-D, plausibly based on the nursing process. AIM: To find out which preferences, assessed by the nursing staff in the pilot study with the PELI-D, were written down in the nursing record. METHODS: An exploratory document analysis was carried out. Included were 13 nursing records and five discussion participants from five institutions in three nursing settings. The data were evaluated descriptively and by a structuring content analysis. RESULTS: A total of 2% of the preferences, which were assessed with the PELI-D, were found in the nursing records and may be due to the use of PELI-D. Preferences mainly from the categories "interventions" and "biography" were found in the nursing record. CONCLUSIONS: 98% of the preferences assessed with the PELI-D were not written down. This can probably be attributed to the fact that the PELI-D was an "innovation" for the nursing staff. Therefore, the execution of an implementation study seems to be reasonable to improve the plausibility of the captured PELI-D data in the nursing documentation. In the context of this, it is also recommended to analyze how the PELI-D influences nursing processes and contents of the nursing record.

An Audit of Dietitians' Documentation - Comparing the Level of Agreement Between the Audit Instruments Diet-NCP-Audit and NCP-QUEST.

To explore the inter-rater reliability of the Swedish translation of NCP-QUEST in a Swedish context and investigate the level of agreement between Diet-NCP-Audit and NCP-QUEST in assessment of documentation quality. A retrospective audit was conducted of 40 electronic patient records written by dietitians at one University Hospital in Sweden. NCP-QUEST showed good inter-rater reliability for the quality category (ICC = 0.85) and excellent inter-rater reliability for total score (ICC = 0.97).

[Analysis of the weaning process in intensive care patients with regard to documentation and transfer to further treatment units]. / Analyse des Weaningprozesses bei Intensivpatienten im Hinblick auf Dokumentation und Verlegung in weiterbehandelnde Einheiten.

BACKGROUND AND OBJECTIVES: Weaning from ventilators is not always finished in the primary intensive care unit (ICU) setting. Transfer to other treatment facilities is a sensitive stage in the treatment and rehabilitation of the weaning patient. The aim of the present study was to investigate transition management and interhospital transfer of weaning patients, with special emphasis on documentation quality. METHODS: A retrospective data analysis of one year (2018) in two ICUs of a university hospital was performed. All ventilated patients with the following tracer diagnoses were included: chronic obstructive pulmonary disease (COPD), asthma, patients with multiple injuries, pneumonia, sepsis, acute respiratory distress syndrome (ARDS), and cardiac arrest (ventilation > 24 h). RESULTS: A total of 750 patients were included in the study (median age 64 [IQR 52.8-76]; 32% female). In all, 48 (6.4%) patients were not weaned at the time of transfer (especially sepsis and ARDS). Routine documentation was sufficient for the sections "spontaneous breathing trial", "assessment of readiness to wean" and "presumed weanability" to adequately assess the parameters of the German S2k guideline "prolonged weaning". Predominantly, these patients were transferred with tracheostoma (76%) to rehabilitation units (44%) by specialized physician-assisted patient transport ambulances (75%). DISCUSSION: The transfer of ventilated patients after initial ICU stay is a relevant issue for interhospital transfer. Routine documentation of a structured weaning process is sufficient in core elements to describe the weaning process. This is of great importance for continuity in the further treatment of these patients.

Understanding how physician perceptions of job demand and process benefits evolve during CPOE implementation.

We examine how physicians' perceptions of two computerized provider order entry (CPOE) capabilities, standardisation of care protocols and documentation quality, are associated with their perceptions of turnaround time, medical error, and job demand at three phases of CPOE implementation: pre-go-live, initial use, and continued use. Through a longitudinal study at a large urban hospital, we find standardisation of care protocols is positively associated with turnaround time reduction in all phases but positively associated with job demand increase only in the initial use phase. Standardisation also has a positive association with medical error reduction in the initial use phase, but later this effect becomes fully mediated through turnaround time reduction in the continued use phase. Documentation quality has a positive association with medical error reduction in the initial use phase and this association strengthens in the continued use phase. Our findings provide insights to effectively manage physicians' response to CPOE implementation.

Quality assessment of point-of-care ultrasound reports for patients at the emergency department treated by internists.

BACKGROUND: POCUS (point-of-care ultrasound) is an important diagnostic tool for several medical specialties. To provide safe patient care, the quality of this exam should be as high as possible. This includes solid documentation with a written report and the availability of images for review. However, international guidelines or publications about this quality assessment and its application in clinical practice are scarce. METHODS: We designed a criteria-checklist to evaluate the quality of POCUS examinations. This checklist was made based on international guidelines and protocols and was validated by a Dutch expert group using the nominal group technique (NGT). All POCUS exams in general internal medicine patients documented between August 2019 and November 2020 in our ED were evaluated using this checklist. RESULTS: A total of 169 exams were included. In general, the compliance for most important criteria was high, but not optimal. A clinical question or indication for the POCUS exam was stated in 75.7% of cases. The completeness of all standard views differed per indication, but was lower when more than one standard view was required. Labels were provided in 83.5% of the saved images, while 90.8% of all examinations showed a written conclusion. CONCLUSIONS: Our research showed that the overall quality of documentation varies with regard to several important criteria. Suboptimal compliance of documentation may have adverse effects on patient safety. We have developed a checklist which can be used to improve POCUS documentation.

Impact of Patient Load on the Quality of Electronic Medical Record Documentation.

OBJECTIVE: American College of Graduate Medical Education (ACGME) recommends ongoing care of 10 patients per resident however its implication is unclear. We hypothesized EMR quality to vary based on patient load and call status. METHODS: We conducted a double-blind, single-center, retrospective observational study between 2017 and 2019 to investigate the quality and accuracy of resident documentation using the Responsible Electronic Documentation (RED) Checklist, a validated scoring system. RESULTS: A total of 234 independent charts were analyzed and 80 met scoring criteria. Average patients per residents was 4, 9.1, 7.2, and 5.5 on "call" day (D0), "post-call" day (D1), "mid-call" day (D2), and "pre-call" day (D3), respectively. Mean RED checklist scores were 68.1%, 57%, 68.6%, and 72.1% on the above call status. The difference in score between D3 and D1 was statistically significant (P = .00042). There was a negative correlation between score and number of patients per resident (r = -0.286, P = .010). CONCLUSION: EMR documentation quality is directly impacted by patient load and resident call status with the lowest documentation quality on post-call day, correlating with patient load.

[Prospective DRG coding : Improvement in cost-effectiveness and documentation quality of in-patient hospital care]. / Fallbegleitende DRG-Kodierung : Verbesserung von Wirtschaftlichkeit und Dokumentationsqualität in der stationären Versorgung.

BACKGROUND: In prospective reimbursement schemes a diagnosis-related group (DRG) is assigned to each case according to all coded diagnoses and procedures. This process can be conducted retrospectively after (DC) or prospectively during the hospitalization (PC). The use of PC offers advantages in terms of cost-effectiveness and documentation quality without impairing patient safety. MATERIAL AND METHODS: A retrospective analysis including all DRG records and billing data from 2012 to 2015 of a surgical department was carried out. The use of PC was introduced into the vascular surgery unit (VS) in September 2013, while the remaining surgical units (RS) stayed with DC. Analysis focused on differences between VS and RS before and after introduction of PC. Characteristics of cost-effectiveness were earnings (EBIT-DA), length of stay (LOS), the case mix index (CMI) and the productivity in relation to the DRG benchmark (productivity index, PI). The number of recorded diagnoses/procedures (ND/NP) was an indicator for documentation quality. RESULTS: A total of 1703 cases with VS and 27,679 cases with RS were analyzed. After introduction of PC the EBIT-DA per case increased in VS but not in RS (+3342 Swiss francs vs. +84, respectively, p < 0.001). The CMI increased slightly in both groups (+0.10 VS vs. +0.08 RS, p > 0.05) and the LOS was more reduced in VS than in RS (-0.36 days vs. -0.03 days, p > 0.005). The PI increased in VS but decreased in RS (+0.131 vs. -0.032, p < 0.001), ND increased more in VS (+1.29 VS vs. +0.26 RS, p < 0.001) and NP remained stable in both groups. CONCLUSION: The use of PC helps to significantly improve cost-effectiveness and documentation quality of in-patient hospital care, essentially by optimizing LOS and cost weight in relation to the DRG benchmark, i. e. increasing the PI. The increasing ND indicates an improvement in documentation quality.

The effect of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction.

INTRODUCTION: Currently, there are few evidence-based guidelines to inform optimal clinical data-entry template design that maximizes usability while reducing unintended consequences. This study explored the impact of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction to identify the most beneficial data-entry methods for use in future documentation interface design. METHODOLOGY: A study using observational data collection and psychometric instruments (for perceived workload and user-satisfaction) was conducted at three hospitals using different methods of data-entry for perioperative documentation (auto-filling with unstructured data, computer-assisted data selection with semi-structured documentation, and paper-based documentation). Nurse anesthetists at each hospital (N = 30) were observed completing documentation on routine abdominal surgical cases. RESULTS: Auto-filling (61.2%) had the lowest documentation accuracy scores compared to computer-assisted (81.3%) and paper-based documentation (76.2%). Computer-assisted data-entry had the best documentation efficiency scores and required the least percentage of the nurse anesthetists' time (9.65%) compared to auto-filling (11.43%) and paper-based documentation (15.23%). Paper-based documentation had the highest perceived workload scores (M = 288, SD = 88) compared to auto-filling (M = 160, SD = 93, U = 16.5, p < 0.01) and computer assisted data-entry (M = 93, SD = 50, U = 4.0, P < 0.001). CONCLUSIONS: Auto-filling with unstructured data needs to be used sparingly because of its low documentation accuracy. Computer-assisted data entry with semi-structured data needs to be further study because of its better documentation accuracy, documentation efficiency, and perceived workload.

Relationship between documentation method and quality of chronic disease visit notes.

OBJECTIVE: To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases. METHODS: Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods. RESULTS: A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001). DISCUSSION: There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists. CONCLUSION: As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.