Evaluating Quality of Electronic Clinical Notes Using the Spanish Version of Physician Documentation Quality Instrument (PDQI-9) in a High-Complexity Hospital. Cross-Sectional Study.

INTRODUCTION: There are factors inherent in Health Information Systems that, when are used improperly, can degrade the quality of the information, which may imply, among other things, the lack of integrity, inconsistency or inaccuracy of the information. OBJECTIVE: The aim of this study is to describe the quality of electronic clinical notes using the PDQI-9 score (Spanish version). METHODS: We evaluated the judgment on the quality of two medical auditors trained in the use of PDQI-9 tool. The unit of analysis was the 3 types of clinical notes: admission notes, progress notes and discharge summaries of adult patients admitted to general wards. Sampling type: random. STATISTICAL ANALYSIS: continuous variables were summarized with median and interquartile range. Medians between 2 reviewers were compared using Mann Whitney hypothesis test. RESULTS: 120 Electronic Health Record (EHR) were selected, the median of the overall quality of the admission notes were 33 (31-34) and 32 (32-37) for each reviewer respectively, without any statistically significant differences (p=0.729). The overall quality of progress notes and discharge summaries were 28 (27-33) vs 27 (27-32), p = 0.175 and 33 (32-34) vs 33 (31-34), p = 0.243, respectively. CONCLUSIONS: The quality of the clinical documents evaluated by the trained reviewers using the PDQI-9 score was good. The application of this type of tool is valuable for making a diagnosis in terms of quality that allows improving clinical documentation, as well as peer communication when reading the Electronic Health Record.

A Path Towards Inclusion: Transdisciplinary Experience for the Inclusion of Self-Perceived Gender in an Information System.

In Argentina, since 2012 the Gender Identity Law guarantees that people who identify as transgender must be called by their chosen name, among other things. Transgender patients are usually not represented in information systems, whether electronic or not. This can place them in situations of vulnerability and discrimination. With that in mind, an interdisciplinary team was formed to take address the problems of this population regarding to the information systems of Hospital Italiano de Buenos Aires. The aim of this study is to spread the experience of the transdisciplinary team on the Electronic Health Record's modification and other associated applications to achieve include the self-perceived gender identity and the chosen name of those people who modified their gender.