title: A Delphi study among internal medicine clinicians to determine which therapeutic information is essential to record in a medical record.
abstract: Several studies have demonstrated that using a template for recording general and diagnostic information in the medical record (MR) improves the completeness of MR documentation, communication between doctors, and performance of doctors. However, little is known about how therapeutic information should be structured in the MR. The aim of this study was to investigate which specific therapeutic information registrars and consultants in internal medicine consider essential to record in the MR. Therefore, we carried out a 2-round Internet Delphi study. Fifty-nine items were assessed on a 5-point scale; an item was considered important if ≥ 80% of the respondents awarded it a score of 4 or 5. In total, 26 registrars and 30 consultants in internal medicine completed both rounds of the study. Overall, they considered it essential to include information about 11 items in the MR. Subgroup analyses revealed that the registrars considered 8 additional items essential, whereas the consultants considered 1 additional item essential to record. Study findings can be used as a starting point to develop a structured section of the MR for therapeutic information for both paper and electronic MRs. This section should contain at least 11 items considered essential by registrars and clinical consultants in internal medicine.
authors.affiliation: RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.|Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: van Unen
authors.affiliation: RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.|Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Jelle
authors.initials: J
authors.lastname: Tichelaar
authors.affiliation: Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Prabath W B
authors.initials: PW
authors.lastname: Nanayakkara
authors.affiliation: RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.|Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands.|Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Michiel A
authors.initials: MA
authors.lastname: van Agtmael
authors.affiliation: RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.|Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Milan C
authors.initials: MC
authors.lastname: Richir
authors.affiliation: RECIPE (Research and Expertise Center In Pharmacotherapy Education), VU University Medical Center, Amsterdam, the Netherlands.|Department of Internal Medicine, Section Pharmacotherapy, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Theo P G M
authors.initials: TP
authors.lastname: de Vries
mesh_terms: D003697:Delphi Technique; D004282:Documentation / Q000379:methods* / Q000592:standards*; D006801:Humans; D007388:Internal Medicine / Q000379:methods* / Q000592:standards*; D008499:Medical Records / Q000592:standards*
keywords: Delphi study; internal medicine; medical records; pharmacotherapy