Department of Internal Medicine, University of Cincinnati College of Medicine, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0535, Cincinnati, OH, 45267, USA.
Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
J Gen Intern Med. 2020 Apr;35(4):1078-1083. doi: 10.1007/s11606-020-05669-6. Epub 2020 Jan 28.
Documentation is a key component of practice, yet few curricula have been published to teach trainees proper note construction. Additionally, a gold standard for assessing note quality does not exist, and no documentation assessment tools integrate with established competency-based frameworks.
To develop and establish initial validity evidence for a novel tool that assesses key components of trainee admission notes and maps to the Accreditation Council for Graduate Medical Education (ACGME) milestone framework.
Using an iterative, consensus building process we developed the Admission Note Assessment Tool (ANAT). Pilot testing was performed with both the supervising attending and study team raters not involved in care of the patients. The finalized tool was piloted with attendings from other institutions.
Local experts participated in tool development and pilot testing. Additional attending physicians participated in pilot testing.
Content, response process, and internal structure validity evidence was gathered using Messick's framework. Inter-rater reliability was assessed using percent agreement.
The final tool consists of 16 checklist items and two global assessment items. Pilot testing demonstrated rater agreement of 72% to 100% for checklist items and 63% to 70% for global assessment items. Note assessment required an average of 12.3 min (SD 3.7). The study generated validity evidence in the domains of content, response process, and internal structure for use of the tool in rating admission notes.
The ANAT assesses individual components of a note, incorporates billing criteria, targets note "bloat," allows for narrative feedback, and provides global assessments mapped to the ACGME milestone framework. The ANAT can be used to assess admission notes by any attending and at any time after note completion with minimal rater training. The ANAT allows programs to implement routine note assessment for multiple functions with the use of a single tool.
文档记录是实践的关键组成部分，但很少有课程被发布来教授受训者正确的记录构建。此外，不存在评估记录质量的黄金标准，也没有任何文档评估工具与既定的基于能力的框架相结合。
开发和建立一种新工具的初步有效性证据，该工具评估学员入院记录的关键组成部分，并与研究生医学教育认证委员会 (ACGME) 的里程碑框架相匹配。
我们使用迭代、共识建立过程开发了入院记录评估工具 (ANAT)。使用未参与患者护理的监督主治医生和研究团队评估员进行了试点测试。最终工具在来自其他机构的主治医生中进行了试点测试。
当地专家参与了工具的开发和试点测试。其他主治医生参与了试点测试。
使用 Messick 的框架收集内容、反应过程和内部结构有效性证据。使用百分比一致性评估评分者间的可靠性。
最终工具由 16 个清单项目和两个总体评估项目组成。试点测试表明，清单项目的评分者间一致性为 72%至 100%，全球评估项目的一致性为 63%至 70%。记录评估平均需要 12.3 分钟（SD 3.7）。该研究在内容、反应过程和内部结构领域生成了有效性证据，用于使用该工具对入院记录进行评分。
ANAT 评估记录的各个组成部分，纳入计费标准，针对记录“膨胀”，允许进行叙述性反馈，并提供与 ACGME 里程碑框架相匹配的全球评估。ANAT 可以由任何主治医生在记录完成后随时使用，只需进行最少的评分者培训即可评估入院记录。ANAT 允许计划使用单个工具实现多种功能的常规记录评估。
