• M Dugas and S Dugas-Breit.
• Institute of Medical Informatics, University of Münster, Domagkstr. 9, 48149 Münster, Germany. dugas@uni-muenster.de
• Method Inform Med. 2012 Jan 1; 51 (3): 252-7.

BackgroundPhysicians 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.ObjectivesA generic method to monitor these quality parameters is proposed and its utility is demonstrated in two examples.MethodsBased 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.ResultsThis 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.ConclusionsMonitoring of completeness and speed of medical documentation is feasible and can provide quantitative information on these processes.

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