Universidade Estadual de Campinas. Campinas, São Paulo, Brazil.
Rev Bras Enferm. 2023 Oct 9;76(4):e20220109. doi: 10.1590/0034-7167-2022-0109. eCollection 2023.
To build and validate the content of an instrument to conduct medical record audits; to conduct a pre-test.
Methodological study conducted from May/2020 to May/2021 in three stages: 1) development of the instrument by bibliographic survey and benchmarking; 2) content validation using the Delphi technique; 3) application of the instrument and descriptive analysis in a sample of 200 medical records.
An instrument was constructed with 11 domains containing sub-items that characterize the quality of care. Two stages of the Delphi technique were necessary to reach a content validity index higher than 0.90. For each domain, a graduated scale with a numerical value from 1 to 4 points was attributed, reflecting the quality of its completion. The average time of application was 35 minutes per record.
The tool proved to be viable to support clinical audits to identify the level of excellence and reveal opportunities for improvement in care processes.
构建并验证用于进行病历审核的工具的内容；进行预测试。
这是一项从 2020 年 5 月至 2021 年 5 月分三个阶段进行的方法学研究：1）通过文献调查和基准测试开发工具；2）使用德尔菲技术进行内容验证；3）在 200 份病历样本中应用该工具并进行描述性分析。
构建了一个包含 11 个领域的工具，其中包含了描述医疗服务质量的子项。德尔菲技术的两个阶段需要达到高于 0.90 的内容有效性指数。对于每个领域，都赋予了一个从 1 到 4 分的渐进式量表，反映其完成的质量。每份记录的平均应用时间为 35 分钟。
该工具被证明是可行的，可以支持临床审核，以确定卓越水平，并揭示医疗服务流程改进的机会。
