Dept. of Medical Informatics and Clinical Epidemiology
Oregon Health & Science University
Introduction: Communication between health care providers is an important factor for the continuity of patient care. In medical records, clinical notes (admission notes, progress notes and discharge summaries) become important for this purpose. The inappropriate use of features of electronic health records (EHRs), such as copy & paste, produces "unreadable" documents with redundant information that reduces the quality of clinical notes. Within this framework, it is essential to assess the quality of clinical notes with a view to implementing mechanisms to improve them. This study proposes to develop a new version of the Physician Documentation Quality Instrument (PDQI-9). This scale evaluates the quality of clinical notes for the purpose of physician communication. Because of a measuring instrument should be reliable and valid beyond the original research population, a cross-cultural validation of the score is critical. Objective: To do a cross-cultural adaptation and validation of the Spanish version of the PDQI-9 score. Methods: This project analyzed the use of the PDQI-9 in Spanish, at Hospital Italiano de Buenos Aires, in electronic clinical notes. The process of cross-cultural validation involved two phases. The first phase comprised the translation and cross-cultural adaptation of the instrument with the participation of an expert panel and a group of Internal Medicine physicians for the pre-test evaluation. The second phase, included the assessment of internal consistency, intra-rater reliability, inter-rater reliability and the evaluation of the criterion validity of the adapted xi instrument. The evaluation of an expert committee represented the gold standard (GS). Results: The translation and adaptation of the score were completed successfully. For the pre-test evaluation, the average time of evaluation of the clinical notes was 17.27 (SD 9.53, min 5, max 46) minutes. In the validation process, 26 physicians were raters and 8 physicians were GS. They performed 898 evaluations, and the evaluation was done in 10.28 (SD 6.81, min 1, max 70) minutes in average. The overall Cronbach's Alpha coefficient was 0.92. For the inter-rater reliability evaluation, the global intra-class correlation coefficient (ICC) for 898 evaluations was 0.92 (95% CI 0.91 - 0.93, p
School of Medicine
Benitez, Sonia E., "Cross-Cultural Adaptation and Validation of a Score for Evaluating the Quality of Inpatient Clinical Notes" (2013). Scholar Archive. 3469.