title: A generic method to monitor completeness and speed of medical documentation processes.
abstract: 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.
  
  
  OBJECTIVE
  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.
authors.affiliation: Institute of Medical Informatics, University of Münster, Domagkstr. 9, 48149 Münster, Germany. dugas@uni-muenster.de
authors.forename: M
authors.initials: M
authors.lastname: Dugas
authors.forename: S
authors.initials: S
authors.lastname: Dugas-Breit
mesh_terms: D004282:Documentation / Q000379:methods*; D004526:Efficiency; D017598:Efficiency, Organizational; D006801:Humans; D008490:Medical Informatics; D016347:Medical Records Systems, Computerized / Q000295:instrumentation*; D010351:Patient Discharge; D011787:Quality of Health Care; D013223:Statistics as Topic; D013647:Task Performance and Analysis; D013995:Time