What is it about?
Structured items used for documentation in electronic health records are usually not disease- and outcome-specific. The selection of such items is usually performed by scientific communities and proposed in international guidelines and recommendations, but not applied for clinical practice. This paper proposes a checklist to configure future documentation tools for simultaneous use in clinical documentation, quality studies and clinical research.
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Why is it important?
To bring together documentation of routine clinical work with needs of clinical research in a single electronic health record.
Perspectives
Needed as soon as electronic health records are flexible enough to be implemented as diseases-specific documentation tools in hospitals and offices.
Michael Schirmer
Medizinische Universitat Innsbruck
Read the Original
This page is a summary of: A Multidisciplinary Delphi Consensus-Based Checklist to Define Clinical Documentation Tools for Both Routine and Research Purposes, Health Services Research and Managerial Epidemiology, January 2018, SAGE Publications,
DOI: 10.1177/2333392817754161.
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