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Assessing the Assessment—Developing and Deploying a Novel Tool for Evaluating Clinical Notes’ Diagnostic Assessment Quality
Background Ambulatory diagnostic errors are increasingly being recognized as an important quality and safety issue, and while measures of diagnostic quality have been sought, tools to evaluate diagnostic assessments in the medical record are lacking. Objective To develop and test a tool to measure d...
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| Published in: | Journal of general internal medicine : JGIM 2023-07, Vol.38 (9), p.2123-2129 |
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| Main Authors: | , , , , , , |
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| Language: | English |
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| container_end_page | 2129 |
| container_issue | 9 |
| container_start_page | 2123 |
| container_title | Journal of general internal medicine : JGIM |
| container_volume | 38 |
| creator | Maria, Mirica Maram, Khazen Sarib, Hussein Jason, Ramos Eguale, Tewodros Mark, Linzer Gordon, Schiff D. |
| description | Background
Ambulatory diagnostic errors are increasingly being recognized as an important quality and safety issue, and while measures of diagnostic quality have been sought, tools to evaluate diagnostic assessments in the medical record are lacking.
Objective
To develop and test a tool to measure diagnostic assessment note quality in primary care urgent encounters and identify common elements and areas for improvement in diagnostic assessment.
Design
Retrospective chart review of urgent care encounters at an urban academic setting.
Participants
Primary care physicians.
Main Measures
The Assessing the Assessment (ATA) instrument was evaluated for inter-rater reliability, internal consistency, and findings from its application to EHR notes.
Key Results
ATA had reasonable performance characteristics (kappa 0.63, overall Cronbach’s alpha 0.76). Variability in diagnostic assessment was seen in several domains. Two components of situational awareness tended to be well-documented (“Don’t miss diagnoses” present in 84% of charts, red flag symptoms in 87%), while Psychosocial context was present only 18% of the time.
Conclusions
The ATA tool is a promising framework for assessing and identifying areas for improvement in diagnostic assessments documented in clinical encounters. |
| doi_str_mv | 10.1007/s11606-023-08085-8 |
| format | article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_10361936</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2781213327</sourcerecordid><originalsourceid>FETCH-LOGICAL-c426t-3ce5cae171e4a1033b86585c7159feea85d4e79cecddcccaf827d389a476d0fd3</originalsourceid><addsrcrecordid>eNp9kU1uFDEQhS0EIpPABVigltiwafC_3SsUzSQQKQpCCmvLcVdPHHnag9090qzIIdhwvZwETzoJCQtWpdL76lWVHkJvCP5AMFYfMyESyxpTVmONtaj1MzQjgoqa8EY9RzOsNa-1YnwP7ed8hTFhlOqXaI9JLbiWaoZ-HuYMOft-WQ2XUE3dCvrh5vrXAjYQ4nqn2b6tFrAOcXvbVWexSNV5jKHqYqqONjaMdthp8-B772woyAD55vp3tfB22cc8ePfIvvo22uCH7Sv0orMhw-u7eoC-Hx-dz7_Up18_n8wPT2vHqRxq5kA4C0QR4JZgxi60FFo4RUTTAVgtWg6qceDa1jlnO01Vy3RjuZIt7lp2gD5NvuvxYgWtKyckG8w6-ZVNWxOtN0-V3l-aZdyYskyShsni8P7OIcUfI-TBrHx2EILtIY7ZUKUJJYxRVdB3_6BXcUx9-c9QzTEnimpSKDpRLsWcE3QP1xBsdgGbKWBTAja3ARtdht4-_uNh5D7RArAJyEXql5D-7v6P7R98WrZ4</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2840417281</pqid></control><display><type>article</type><title>Assessing the Assessment—Developing and Deploying a Novel Tool for Evaluating Clinical Notes’ Diagnostic Assessment Quality</title><source>PubMed (Medline)</source><source>Springer Link</source><creator>Maria, Mirica ; Maram, Khazen ; Sarib, Hussein ; Jason, Ramos ; Eguale, Tewodros ; Mark, Linzer ; Gordon, Schiff D.</creator><creatorcontrib>Maria, Mirica ; Maram, Khazen ; Sarib, Hussein ; Jason, Ramos ; Eguale, Tewodros ; Mark, Linzer ; Gordon, Schiff D.</creatorcontrib><description>Background
Ambulatory diagnostic errors are increasingly being recognized as an important quality and safety issue, and while measures of diagnostic quality have been sought, tools to evaluate diagnostic assessments in the medical record are lacking.
Objective
To develop and test a tool to measure diagnostic assessment note quality in primary care urgent encounters and identify common elements and areas for improvement in diagnostic assessment.
Design
Retrospective chart review of urgent care encounters at an urban academic setting.
Participants
Primary care physicians.
Main Measures
The Assessing the Assessment (ATA) instrument was evaluated for inter-rater reliability, internal consistency, and findings from its application to EHR notes.
Key Results
ATA had reasonable performance characteristics (kappa 0.63, overall Cronbach’s alpha 0.76). Variability in diagnostic assessment was seen in several domains. Two components of situational awareness tended to be well-documented (“Don’t miss diagnoses” present in 84% of charts, red flag symptoms in 87%), while Psychosocial context was present only 18% of the time.
Conclusions
The ATA tool is a promising framework for assessing and identifying areas for improvement in diagnostic assessments documented in clinical encounters.</description><identifier>ISSN: 0884-8734</identifier><identifier>ISSN: 1525-1497</identifier><identifier>EISSN: 1525-1497</identifier><identifier>DOI: 10.1007/s11606-023-08085-8</identifier><identifier>PMID: 36854867</identifier><language>eng</language><publisher>Cham: Springer International Publishing</publisher><subject>Ambulatory Care ; Charts ; Diagnostic Errors - prevention & control ; Electronic health records ; Health care ; Humans ; Internal Medicine ; Medical diagnosis ; Medical Records ; Medicine ; Medicine & Public Health ; Original Research ; Primary care ; Quality assessment ; Reproducibility of Results ; Retrospective Studies ; Situational awareness</subject><ispartof>Journal of general internal medicine : JGIM, 2023-07, Vol.38 (9), p.2123-2129</ispartof><rights>The Author(s), under exclusive licence to Society of General Internal Medicine 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</rights><rights>2023. The Author(s), under exclusive licence to Society of General Internal Medicine.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c426t-3ce5cae171e4a1033b86585c7159feea85d4e79cecddcccaf827d389a476d0fd3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC10361936/pdf/$$EPDF$$P50$$Gpubmedcentral$$H</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC10361936/$$EHTML$$P50$$Gpubmedcentral$$H</linktohtml><link.rule.ids>230,315,733,786,790,891,27957,27958,53827,53829</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/36854867$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Maria, Mirica</creatorcontrib><creatorcontrib>Maram, Khazen</creatorcontrib><creatorcontrib>Sarib, Hussein</creatorcontrib><creatorcontrib>Jason, Ramos</creatorcontrib><creatorcontrib>Eguale, Tewodros</creatorcontrib><creatorcontrib>Mark, Linzer</creatorcontrib><creatorcontrib>Gordon, Schiff D.</creatorcontrib><title>Assessing the Assessment—Developing and Deploying a Novel Tool for Evaluating Clinical Notes’ Diagnostic Assessment Quality</title><title>Journal of general internal medicine : JGIM</title><addtitle>J GEN INTERN MED</addtitle><addtitle>J Gen Intern Med</addtitle><description>Background
Ambulatory diagnostic errors are increasingly being recognized as an important quality and safety issue, and while measures of diagnostic quality have been sought, tools to evaluate diagnostic assessments in the medical record are lacking.
Objective
To develop and test a tool to measure diagnostic assessment note quality in primary care urgent encounters and identify common elements and areas for improvement in diagnostic assessment.
Design
Retrospective chart review of urgent care encounters at an urban academic setting.
Participants
Primary care physicians.
Main Measures
The Assessing the Assessment (ATA) instrument was evaluated for inter-rater reliability, internal consistency, and findings from its application to EHR notes.
Key Results
ATA had reasonable performance characteristics (kappa 0.63, overall Cronbach’s alpha 0.76). Variability in diagnostic assessment was seen in several domains. Two components of situational awareness tended to be well-documented (“Don’t miss diagnoses” present in 84% of charts, red flag symptoms in 87%), while Psychosocial context was present only 18% of the time.
Conclusions
The ATA tool is a promising framework for assessing and identifying areas for improvement in diagnostic assessments documented in clinical encounters.</description><subject>Ambulatory Care</subject><subject>Charts</subject><subject>Diagnostic Errors - prevention & control</subject><subject>Electronic health records</subject><subject>Health care</subject><subject>Humans</subject><subject>Internal Medicine</subject><subject>Medical diagnosis</subject><subject>Medical Records</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Original Research</subject><subject>Primary care</subject><subject>Quality assessment</subject><subject>Reproducibility of Results</subject><subject>Retrospective Studies</subject><subject>Situational awareness</subject><issn>0884-8734</issn><issn>1525-1497</issn><issn>1525-1497</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2023</creationdate><recordtype>article</recordtype><recordid>eNp9kU1uFDEQhS0EIpPABVigltiwafC_3SsUzSQQKQpCCmvLcVdPHHnag9090qzIIdhwvZwETzoJCQtWpdL76lWVHkJvCP5AMFYfMyESyxpTVmONtaj1MzQjgoqa8EY9RzOsNa-1YnwP7ed8hTFhlOqXaI9JLbiWaoZ-HuYMOft-WQ2XUE3dCvrh5vrXAjYQ4nqn2b6tFrAOcXvbVWexSNV5jKHqYqqONjaMdthp8-B772woyAD55vp3tfB22cc8ePfIvvo22uCH7Sv0orMhw-u7eoC-Hx-dz7_Up18_n8wPT2vHqRxq5kA4C0QR4JZgxi60FFo4RUTTAVgtWg6qceDa1jlnO01Vy3RjuZIt7lp2gD5NvuvxYgWtKyckG8w6-ZVNWxOtN0-V3l-aZdyYskyShsni8P7OIcUfI-TBrHx2EILtIY7ZUKUJJYxRVdB3_6BXcUx9-c9QzTEnimpSKDpRLsWcE3QP1xBsdgGbKWBTAja3ARtdht4-_uNh5D7RArAJyEXql5D-7v6P7R98WrZ4</recordid><startdate>20230701</startdate><enddate>20230701</enddate><creator>Maria, Mirica</creator><creator>Maram, Khazen</creator><creator>Sarib, Hussein</creator><creator>Jason, Ramos</creator><creator>Eguale, Tewodros</creator><creator>Mark, Linzer</creator><creator>Gordon, Schiff D.</creator><general>Springer International Publishing</general><general>Springer Nature B.V</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QL</scope><scope>7RV</scope><scope>7U9</scope><scope>7X7</scope><scope>7XB</scope><scope>88C</scope><scope>8AO</scope><scope>8FD</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>C1K</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>H94</scope><scope>K9.</scope><scope>M0S</scope><scope>M0T</scope><scope>M1P</scope><scope>M2O</scope><scope>M7N</scope><scope>MBDVC</scope><scope>NAPCQ</scope><scope>P64</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>Q9U</scope><scope>RC3</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20230701</creationdate><title>Assessing the Assessment—Developing and Deploying a Novel Tool for Evaluating Clinical Notes’ Diagnostic Assessment Quality</title><author>Maria, Mirica ; Maram, Khazen ; Sarib, Hussein ; Jason, Ramos ; Eguale, Tewodros ; Mark, Linzer ; Gordon, Schiff D.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c426t-3ce5cae171e4a1033b86585c7159feea85d4e79cecddcccaf827d389a476d0fd3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2023</creationdate><topic>Ambulatory Care</topic><topic>Charts</topic><topic>Diagnostic Errors - prevention & control</topic><topic>Electronic health records</topic><topic>Health care</topic><topic>Humans</topic><topic>Internal Medicine</topic><topic>Medical diagnosis</topic><topic>Medical Records</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Original Research</topic><topic>Primary care</topic><topic>Quality assessment</topic><topic>Reproducibility of Results</topic><topic>Retrospective Studies</topic><topic>Situational awareness</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Maria, Mirica</creatorcontrib><creatorcontrib>Maram, Khazen</creatorcontrib><creatorcontrib>Sarib, Hussein</creatorcontrib><creatorcontrib>Jason, Ramos</creatorcontrib><creatorcontrib>Eguale, Tewodros</creatorcontrib><creatorcontrib>Mark, Linzer</creatorcontrib><creatorcontrib>Gordon, Schiff D.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>ProQuest Nursing & Allied Health Database</collection><collection>Virology and AIDS Abstracts</collection><collection>ProQuest Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Healthcare Administration Database (Alumni)</collection><collection>ProQuest Pharma Collection</collection><collection>Technology Research Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni)</collection><collection>ProQuest Central</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Health Management Database (Proquest)</collection><collection>Medical Database</collection><collection>ProQuest Research Library</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central Basic</collection><collection>Genetics Abstracts</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Journal of general internal medicine : JGIM</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Maria, Mirica</au><au>Maram, Khazen</au><au>Sarib, Hussein</au><au>Jason, Ramos</au><au>Eguale, Tewodros</au><au>Mark, Linzer</au><au>Gordon, Schiff D.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Assessing the Assessment—Developing and Deploying a Novel Tool for Evaluating Clinical Notes’ Diagnostic Assessment Quality</atitle><jtitle>Journal of general internal medicine : JGIM</jtitle><stitle>J GEN INTERN MED</stitle><addtitle>J Gen Intern Med</addtitle><date>2023-07-01</date><risdate>2023</risdate><volume>38</volume><issue>9</issue><spage>2123</spage><epage>2129</epage><pages>2123-2129</pages><issn>0884-8734</issn><issn>1525-1497</issn><eissn>1525-1497</eissn><notes>ObjectType-Article-1</notes><notes>SourceType-Scholarly Journals-1</notes><notes>ObjectType-Feature-2</notes><notes>content type line 23</notes><abstract>Background
Ambulatory diagnostic errors are increasingly being recognized as an important quality and safety issue, and while measures of diagnostic quality have been sought, tools to evaluate diagnostic assessments in the medical record are lacking.
Objective
To develop and test a tool to measure diagnostic assessment note quality in primary care urgent encounters and identify common elements and areas for improvement in diagnostic assessment.
Design
Retrospective chart review of urgent care encounters at an urban academic setting.
Participants
Primary care physicians.
Main Measures
The Assessing the Assessment (ATA) instrument was evaluated for inter-rater reliability, internal consistency, and findings from its application to EHR notes.
Key Results
ATA had reasonable performance characteristics (kappa 0.63, overall Cronbach’s alpha 0.76). Variability in diagnostic assessment was seen in several domains. Two components of situational awareness tended to be well-documented (“Don’t miss diagnoses” present in 84% of charts, red flag symptoms in 87%), while Psychosocial context was present only 18% of the time.
Conclusions
The ATA tool is a promising framework for assessing and identifying areas for improvement in diagnostic assessments documented in clinical encounters.</abstract><cop>Cham</cop><pub>Springer International Publishing</pub><pmid>36854867</pmid><doi>10.1007/s11606-023-08085-8</doi><tpages>7</tpages><oa>free_for_read</oa></addata></record> |
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| identifier | ISSN: 0884-8734 |
| ispartof | Journal of general internal medicine : JGIM, 2023-07, Vol.38 (9), p.2123-2129 |
| issn | 0884-8734 1525-1497 1525-1497 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_10361936 |
| source | PubMed (Medline); Springer Link |
| subjects | Ambulatory Care Charts Diagnostic Errors - prevention & control Electronic health records Health care Humans Internal Medicine Medical diagnosis Medical Records Medicine Medicine & Public Health Original Research Primary care Quality assessment Reproducibility of Results Retrospective Studies Situational awareness |
| title | Assessing the Assessment—Developing and Deploying a Novel Tool for Evaluating Clinical Notes’ Diagnostic Assessment Quality |
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