Pollock Nathaniel J, Yantha Cassandra, Tonmyr Lil, Jewers-Dailley Kimberly, Morton Ninomiya Melody E
Family Violence Epidemiology Section, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada.
Inuit Tapiriit Kanatami, Ottawa, Ontario, Canada.
PLoS One. 2025 Jan 7;20(1):e0316238. doi: 10.1371/journal.pone.0316238. eCollection 2025.
In health care and child welfare, clinical records and case notes serve multiple functions. When records are aggregated and processed to create administrative data, they can be analyzed and used to inform policy development and decision-making. To be useful, such data should be complete, accurate, and recorded in a standardized way. However, sources of bias and error can impact the quality of administrative data. During the development of national child welfare data in Canada, child welfare sector partners expressed concerns about the accuracy and completeness of data about children and families. This protocol describes a study that seeks to answer two questions: 1) What individual and institutional factors influence how client data is recorded by child welfare workers in Canada? 2) What data quality issues are created through documentation and case recording practices that may impact the use of clinical case management system data for public health statistics? In this protocol, we describe an exploratory mixed methods study that involves an online survey, interviews with a purposive sample of child welfare workers, and a document review of case recording guidelines. To be eligible for the study, participants must have worked at a child welfare agency or department with clinical documentation responsibilities as a part of their job. We will use descriptive statistics to analyze the survey data and thematic analysis to analyze the qualitative data. This study will help uncover strengths, limitations, and possible sources of bias created through case recording and documentation practices in child welfare. Study results will be shared through presentations to interest holders and will inform the further development of national child welfare data in Canada.
在医疗保健和儿童福利领域，临床记录和病例笔记具有多种功能。当记录被汇总和处理以创建行政数据时，这些数据可以进行分析并用于为政策制定和决策提供信息。为了使其有用，此类数据应完整、准确且以标准化方式记录。然而，偏差和错误来源可能会影响行政数据的质量。在加拿大国家儿童福利数据的开发过程中，儿童福利部门的合作伙伴对有关儿童和家庭数据的准确性和完整性表示担忧。本方案描述了一项旨在回答两个问题的研究：1）加拿大儿童福利工作者记录客户数据时，哪些个人和机构因素会产生影响？2）通过文档记录和病例记录实践会产生哪些可能影响将临床病例管理系统数据用于公共卫生统计的数据质量问题？在本方案中，我们描述了一项探索性混合方法研究，该研究包括一项在线调查、对有目的抽样的儿童福利工作者进行访谈以及对病例记录指南的文档审查。要符合该研究的条件，参与者必须在有临床文档记录职责的儿童福利机构或部门工作。我们将使用描述性统计分析调查数据，使用主题分析来分析定性数据。本研究将有助于揭示儿童福利领域病例记录和文档记录实践所产生的优势、局限性以及可能的偏差来源。研究结果将通过向利益相关者汇报进行分享，并为加拿大国家儿童福利数据的进一步发展提供参考。
