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A comparison of mental state examination documentation by junior clinicians in electronic health records before and after the introduction of a semi-structured assessment template (OPCRIT+).

Lobo SE, Rucker J, Kerr M, Gallo F, Constable G, Hotopf M, Stewart R, Broadbent M, Baggaley M, Lovestone S, McGuffin P, Amarasinghe M, Newman S, Schumann G, Brittain PJ - Int J Med Inform (2015)

Bottom Line: Second, we conducted an audit to compare the frequency with which individual components of the MSE were documented in the normal MSEs compared with the OPCRIT+MSEs.These results indicate that a semi-structured assessment template significantly improves the quality of MSE recording by junior doctors within EHRs.Future work should focus on whether such improvements translate into better patient outcomes and have the ability to improve the quality of information available on EHRs to researchers.

View Article: PubMed Central - PubMed

Affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.

No MeSH data available.


Example of an OPCRIT+ (Example 1) and normal MSE (Example 2). Examples chosen were both ranked twenty-fifth out of fifty based on a mean of all three raters mean scores for the ratings ‘Thorough’, ‘Useful’, ‘Organized’, ‘Comprehensible’ and ‘General Impression of Note Quality’. For the OPCRIT + MSE this mean of means was 3.3 and for the normal MSE it was 2.8 (from a maximum of five). All typos are as they were in the original text.
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fig0005: Example of an OPCRIT+ (Example 1) and normal MSE (Example 2). Examples chosen were both ranked twenty-fifth out of fifty based on a mean of all three raters mean scores for the ratings ‘Thorough’, ‘Useful’, ‘Organized’, ‘Comprehensible’ and ‘General Impression of Note Quality’. For the OPCRIT + MSE this mean of means was 3.3 and for the normal MSE it was 2.8 (from a maximum of five). All typos are as they were in the original text.

Mentions: In relation to the consultant's ratings, the OPCRIT + MSEs were scored significantly higher than the normal MSEs on the PDQI-9 judgements of ‘Thorough’, ‘Useful’, ‘Organized’ and ‘Comprehensible’ as well as in terms of ‘General Impression of Note Quality’. On a five-point scale, mean judgements ranged between 0.42 and 0.66 points higher for the OPCRIT + MSEs, with the greatest difference for how ‘Organized’ they were thought to be (Table 1). Across all five judgements, this equated to a mean 11% improvement in the quality of MSEs when written with the semi-structured template (see Fig. 1 for examples). Unfortunately, we could not consider the two PDQI-9 judgements where inter-rater reliability was not of an acceptable standard. In the case of ‘Internally consistent’, it may have been that this confused the consultants; MSEs are typically brief documents, stating a few core observations and probably have little room to be internally inconsistent (i.e. they rarely have enough content to contradict themselves). In terms of the ‘Succinct’ judgement, it may simply be that one consultant's notion of a succinct MSE is different from another's and this led to rating inconsistency.


A comparison of mental state examination documentation by junior clinicians in electronic health records before and after the introduction of a semi-structured assessment template (OPCRIT+).

Lobo SE, Rucker J, Kerr M, Gallo F, Constable G, Hotopf M, Stewart R, Broadbent M, Baggaley M, Lovestone S, McGuffin P, Amarasinghe M, Newman S, Schumann G, Brittain PJ - Int J Med Inform (2015)

Example of an OPCRIT+ (Example 1) and normal MSE (Example 2). Examples chosen were both ranked twenty-fifth out of fifty based on a mean of all three raters mean scores for the ratings ‘Thorough’, ‘Useful’, ‘Organized’, ‘Comprehensible’ and ‘General Impression of Note Quality’. For the OPCRIT + MSE this mean of means was 3.3 and for the normal MSE it was 2.8 (from a maximum of five). All typos are as they were in the original text.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4526540&req=5

fig0005: Example of an OPCRIT+ (Example 1) and normal MSE (Example 2). Examples chosen were both ranked twenty-fifth out of fifty based on a mean of all three raters mean scores for the ratings ‘Thorough’, ‘Useful’, ‘Organized’, ‘Comprehensible’ and ‘General Impression of Note Quality’. For the OPCRIT + MSE this mean of means was 3.3 and for the normal MSE it was 2.8 (from a maximum of five). All typos are as they were in the original text.
Mentions: In relation to the consultant's ratings, the OPCRIT + MSEs were scored significantly higher than the normal MSEs on the PDQI-9 judgements of ‘Thorough’, ‘Useful’, ‘Organized’ and ‘Comprehensible’ as well as in terms of ‘General Impression of Note Quality’. On a five-point scale, mean judgements ranged between 0.42 and 0.66 points higher for the OPCRIT + MSEs, with the greatest difference for how ‘Organized’ they were thought to be (Table 1). Across all five judgements, this equated to a mean 11% improvement in the quality of MSEs when written with the semi-structured template (see Fig. 1 for examples). Unfortunately, we could not consider the two PDQI-9 judgements where inter-rater reliability was not of an acceptable standard. In the case of ‘Internally consistent’, it may have been that this confused the consultants; MSEs are typically brief documents, stating a few core observations and probably have little room to be internally inconsistent (i.e. they rarely have enough content to contradict themselves). In terms of the ‘Succinct’ judgement, it may simply be that one consultant's notion of a succinct MSE is different from another's and this led to rating inconsistency.

Bottom Line: Second, we conducted an audit to compare the frequency with which individual components of the MSE were documented in the normal MSEs compared with the OPCRIT+MSEs.These results indicate that a semi-structured assessment template significantly improves the quality of MSE recording by junior doctors within EHRs.Future work should focus on whether such improvements translate into better patient outcomes and have the ability to improve the quality of information available on EHRs to researchers.

View Article: PubMed Central - PubMed

Affiliation: National Institute for Health Research (NIHR), Biomedical Research Centre and Dementia Unit at South London and Maudsley National Health Service Foundation Trust and King's College London, London, United Kingdom.

No MeSH data available.