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Veraar C, Hasler P, Schirmer M. A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and Research Purposes. Health Serv Res Manag Epidemiol. 2018;5:2333392817754161doi: 10.1177/2333392817754161.
Veraar, C., Hasler, P., & Schirmer, M. (2018). A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and Research Purposes. Health services research and managerial epidemiology, 52333392817754161. https://doi.org/10.1177/2333392817754161
Veraar, Cecilia, et al. "A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and Research Purposes." Health services research and managerial epidemiology vol. 5 (2018): 2333392817754161. doi: https://doi.org/10.1177/2333392817754161
Veraar C, Hasler P, Schirmer M. A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and Research Purposes. Health Serv Res Manag Epidemiol. 2018 Feb 06;5:2333392817754161. doi: 10.1177/2333392817754161. eCollection 2018. PMID: 29450216; PMCID: PMC5808956.
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Health Serv Res Manag Epidemiol. 2018 Feb 06;5:2333392817754161. doi: 10.1177/2333392817754161. eCollection 2018.

A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and Research Purposes.

Health services research and managerial epidemiology

Cecilia Veraar, Paul Hasler, Michael Schirmer

Affiliations

  1. Department of Internal Medicine, Clinic II, Medizinische Universität Innsbruck, Innsbruck, Austria.
  2. Division of Rheumatology, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland.

PMID: 29450216 PMCID: PMC5808956 DOI: 10.1177/2333392817754161

Abstract

BACKGROUND: To the best of our knowledge, a strategic approach to define the contents of structured clinical documentation tools for both clinical routine patient care and research purposes has not been reported so far, although electronic health record will become more and more structured and detailed in the future.

OBJECTIVE: To achieve an interdisciplinary consensus on a checklist to be considered for the preparation of disease- and situation-specific clinical documentation tools.

METHODS: A 2-round Delphi consensus-based process was conducted both with 19 physicians of different disciplines and 14 students from Austria, Switzerland, and Germany. Agreement was defined as 80% or more positive votes of the participants.

RESULTS: The participants agreed that a working group should be set up for the development of structured disease- or situation-specific documentation tools (97% agreement). The final checklist included 4 recommendations concerning the setup of the working group, 12 content-related recommendations, and 3 general and technical recommendations (mean agreement [standard deviation] = 97.4% [4.0%], ranging from 84.2% to 100.0%).

DISCUSSION AND CONCLUSION: In the future, disease- and situation-specific structured documentation tools will provide an important bridge between registries and electronic health records. Clinical documentation tools defined according to this Delphi consensus-based checklist will provide data for registries while serving as high-quality data acquisition tools in routine clinical care.

Keywords: clinical; disease management; documentation; health-care records; health-care research; managed care; managerial epidemiology; medical informatics

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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