• About
    • Login
    View Item 
    •   Institutional Repository Home
    • Electronic Theses and Dissertations
    • Electronic Theses and Dissertations
    • View Item
    •   Institutional Repository Home
    • Electronic Theses and Dissertations
    • Electronic Theses and Dissertations
    • View Item
    JavaScript is disabled for your browser. Some features of this site may not work without it.

    Browse

    All of Institutional RepositoryCommunities & CollectionsBy Issue DateAuthorsTitlesSubjectsDepartmentThis CollectionBy Issue DateAuthorsTitlesSubjectsDepartment

    My Account

    LoginRegister

    Clinical Encounter Information Flow: Applications In Evaluating Medical Documentation Tools

    Khan, Naqi Ali
    : https://etd.library.vanderbilt.edu/etd-11262012-114245
    http://hdl.handle.net/1803/14813
    : 2012-12-10

    Abstract

    There is little research on how clinically relevant concepts are transferred from a patient, through a healthcare provider, and then to a resultant clinical note. This study tested whether clinical information flow, defined as the transfer of concepts from patient to note, can be traced. The study's investigators also analyzed the impact of a clinical documentation tool on note content. Healthcare providers, designated as clinical simulation study subjects, generated clinical notes via two documentation tools. The simulation utilized standardized patient scenario descriptions (PSDs). Independent physician reviewers identified clinical concepts present in the PSDs and in resultant clinic notes. Reviewers identified a total of 256 unique clinical concepts across all PSDs. Of these, a total of 122 unique concepts overlapped for the PSDs and resultant notes from both documentation tools. Additionally, the dictation-based and computer-based notes shared 103 distinct concepts not found in the PSDs. This study's findings suggest that both computer-based and dictation-based tools are subject to clinical concept loss. Templates may have eased documentation, partly explaining the greater concept count for computer-based notes. This study found that tracing information flow in a clinical simulation encounter is a valid method for evaluating medical documentation tools. Clinical note template availability also likely impacts healthcare provider documentation.
    Show full item record

    Files in this item

    Icon
    Name:
    NaqiKhan_MastersThesis.pdf
    Size:
    4.225Mb
    Format:
    PDF
    View/Open

    This item appears in the following collection(s):

    • Electronic Theses and Dissertations

    Connect with Vanderbilt Libraries

    Your Vanderbilt

    • Alumni
    • Current Students
    • Faculty & Staff
    • International Students
    • Media
    • Parents & Family
    • Prospective Students
    • Researchers
    • Sports Fans
    • Visitors & Neighbors

    Support the Jean and Alexander Heard Libraries

    Support the Library...Give Now

    Gifts to the Libraries support the learning and research needs of the entire Vanderbilt community. Learn more about giving to the Libraries.

    Become a Friend of the Libraries

    Quick Links

    • Hours
    • About
    • Employment
    • Staff Directory
    • Accessibility Services
    • Contact
    • Vanderbilt Home
    • Privacy Policy