{"id":"https://openalex.org/W3036201857","doi":"https://doi.org/10.3233/shti200228","title":"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","display_name":"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","publication_year":2020,"publication_date":"2020-01-01","ids":{"openalex":"https://openalex.org/W3036201857","doi":"https://doi.org/10.3233/shti200228","mag":"3036201857","pmid":"https://pubmed.ncbi.nlm.nih.gov/32570451"},"language":"en","primary_location":{"id":"doi:10.3233/shti200228","is_oa":true,"landing_page_url":"https://doi.org/10.3233/shti200228","pdf_url":null,"source":{"id":"https://openalex.org/S4210179765","display_name":"Studies in health technology and informatics","issn_l":"0926-9630","issn":["0926-9630","1879-8365"],"is_oa":false,"is_in_doaj":false,"is_core":true,"host_organization":"https://openalex.org/P4310318577","host_organization_name":"IOS Press","host_organization_lineage":["https://openalex.org/P4310318577"],"host_organization_lineage_names":["IOS Press"],"type":"book series"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in Health Technology and Informatics","raw_type":"book-chapter"},"type":"article","indexed_in":["crossref","pubmed"],"open_access":{"is_oa":true,"oa_status":"hybrid","oa_url":"https://doi.org/10.3233/shti200228","any_repository_has_fulltext":false},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5075986122","display_name":"Giuliana Colussi","orcid":"https://orcid.org/0000-0002-2137-471X"},"institutions":[{"id":"https://openalex.org/I2802359038","display_name":"Hospital Italiano de Buenos Aires","ror":"https://ror.org/00bq4rw46","country_code":"AR","type":"healthcare","lineage":["https://openalex.org/I2802359038"]}],"countries":["AR"],"is_corresponding":false,"raw_author_name":"Colussi Giuliana","raw_affiliation_strings":["Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina","institution_ids":["https://openalex.org/I2802359038"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5019035781","display_name":"Amalia Botto","orcid":null},"institutions":[{"id":"https://openalex.org/I2802359038","display_name":"Hospital Italiano de Buenos Aires","ror":"https://ror.org/00bq4rw46","country_code":"AR","type":"healthcare","lineage":["https://openalex.org/I2802359038"]}],"countries":["AR"],"is_corresponding":false,"raw_author_name":"Botto Amalia","raw_affiliation_strings":["Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina","institution_ids":["https://openalex.org/I2802359038"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5041152488","display_name":"Romina Giudicessi","orcid":null},"institutions":[{"id":"https://openalex.org/I2802359038","display_name":"Hospital Italiano de Buenos Aires","ror":"https://ror.org/00bq4rw46","country_code":"AR","type":"healthcare","lineage":["https://openalex.org/I2802359038"]}],"countries":["AR"],"is_corresponding":false,"raw_author_name":"Giudicessi Romina","raw_affiliation_strings":["Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina","institution_ids":["https://openalex.org/I2802359038"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5039257658","display_name":"Laura Gomel","orcid":null},"institutions":[{"id":"https://openalex.org/I2802359038","display_name":"Hospital Italiano de Buenos Aires","ror":"https://ror.org/00bq4rw46","country_code":"AR","type":"healthcare","lineage":["https://openalex.org/I2802359038"]}],"countries":["AR"],"is_corresponding":false,"raw_author_name":"Gomel Laura","raw_affiliation_strings":["Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina","institution_ids":["https://openalex.org/I2802359038"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5080259851","display_name":"Aldo Marangone","orcid":null},"institutions":[{"id":"https://openalex.org/I2802359038","display_name":"Hospital Italiano de Buenos Aires","ror":"https://ror.org/00bq4rw46","country_code":"AR","type":"healthcare","lineage":["https://openalex.org/I2802359038"]}],"countries":["AR"],"is_corresponding":false,"raw_author_name":"Marangone Aldo","raw_affiliation_strings":["Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina","institution_ids":["https://openalex.org/I2802359038"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5072038269","display_name":"Miguel Rodr\u00edguez","orcid":null},"institutions":[{"id":"https://openalex.org/I2802359038","display_name":"Hospital Italiano de Buenos Aires","ror":"https://ror.org/00bq4rw46","country_code":"AR","type":"healthcare","lineage":["https://openalex.org/I2802359038"]}],"countries":["AR"],"is_corresponding":false,"raw_author_name":"Rodriguez Miguel","raw_affiliation_strings":["Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Medical Auditing Department, Hospital Italiano de Buenos Aires, Argentina","institution_ids":["https://openalex.org/I2802359038"]}]},{"author_position":"last","author":{"id":"https://openalex.org/A5103274487","display_name":"Sonia Ben\u00edtez","orcid":"https://orcid.org/0000-0001-6648-1984"},"institutions":[{"id":"https://openalex.org/I2802359038","display_name":"Hospital Italiano de Buenos Aires","ror":"https://ror.org/00bq4rw46","country_code":"AR","type":"healthcare","lineage":["https://openalex.org/I2802359038"]}],"countries":["AR"],"is_corresponding":false,"raw_author_name":"Benitez Sonia","raw_affiliation_strings":["Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina","institution_ids":["https://openalex.org/I2802359038"]}]}],"institutions":[],"countries_distinct_count":1,"institutions_distinct_count":1,"corresponding_author_ids":[],"corresponding_institution_ids":["https://openalex.org/I2802359038"],"apc_list":null,"apc_paid":null,"fwci":0.0,"has_fulltext":false,"cited_by_count":1,"citation_normalized_percentile":{"value":0.1317402,"is_in_top_1_percent":false,"is_in_top_10_percent":false},"cited_by_percentile_year":{"min":95,"max":97},"biblio":{"volume":"270","issue":null,"first_page":"587","last_page":"591"},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T10350","display_name":"Electronic Health Records Systems","score":0.40290001034736633,"subfield":{"id":"https://openalex.org/subfields/3605","display_name":"Health Information Management"},"field":{"id":"https://openalex.org/fields/36","display_name":"Health Professions"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},"topics":[{"id":"https://openalex.org/T10350","display_name":"Electronic Health Records Systems","score":0.40290001034736633,"subfield":{"id":"https://openalex.org/subfields/3605","display_name":"Health Information Management"},"field":{"id":"https://openalex.org/fields/36","display_name":"Health Professions"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T12790","display_name":"Nursing Diagnosis and Documentation","score":0.39500001072883606,"subfield":{"id":"https://openalex.org/subfields/2910","display_name":"Issues, ethics and legal aspects"},"field":{"id":"https://openalex.org/fields/29","display_name":"Nursing"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T14400","display_name":"Medical Coding and Health Information","score":0.08060000091791153,"subfield":{"id":"https://openalex.org/subfields/3605","display_name":"Health Information Management"},"field":{"id":"https://openalex.org/fields/36","display_name":"Health Professions"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/documentation","display_name":"Documentation","score":0.813008189201355},{"id":"https://openalex.org/keywords/quality","display_name":"Quality (philosophy)","score":0.6381720304489136},{"id":"https://openalex.org/keywords/cross-sectional-study","display_name":"Cross-sectional study","score":0.5526443719863892},{"id":"https://openalex.org/keywords/medicine","display_name":"Medicine","score":0.44678744673728943},{"id":"https://openalex.org/keywords/family-medicine","display_name":"Family medicine","score":0.3959137499332428},{"id":"https://openalex.org/keywords/psychology","display_name":"Psychology","score":0.3356497883796692},{"id":"https://openalex.org/keywords/computer-science","display_name":"Computer science","score":0.26681822538375854},{"id":"https://openalex.org/keywords/pathology","display_name":"Pathology","score":0.05247071385383606},{"id":"https://openalex.org/keywords/operating-system","display_name":"Operating system","score":0.0489906370639801}],"concepts":[{"id":"https://openalex.org/C56666940","wikidata":"https://www.wikidata.org/wiki/Q788790","display_name":"Documentation","level":2,"score":0.813008189201355},{"id":"https://openalex.org/C2779530757","wikidata":"https://www.wikidata.org/wiki/Q1207505","display_name":"Quality (philosophy)","level":2,"score":0.6381720304489136},{"id":"https://openalex.org/C142052008","wikidata":"https://www.wikidata.org/wiki/Q954027","display_name":"Cross-sectional study","level":2,"score":0.5526443719863892},{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.44678744673728943},{"id":"https://openalex.org/C512399662","wikidata":"https://www.wikidata.org/wiki/Q3505712","display_name":"Family medicine","level":1,"score":0.3959137499332428},{"id":"https://openalex.org/C15744967","wikidata":"https://www.wikidata.org/wiki/Q9418","display_name":"Psychology","level":0,"score":0.3356497883796692},{"id":"https://openalex.org/C41008148","wikidata":"https://www.wikidata.org/wiki/Q21198","display_name":"Computer science","level":0,"score":0.26681822538375854},{"id":"https://openalex.org/C142724271","wikidata":"https://www.wikidata.org/wiki/Q7208","display_name":"Pathology","level":1,"score":0.05247071385383606},{"id":"https://openalex.org/C111919701","wikidata":"https://www.wikidata.org/wiki/Q9135","display_name":"Operating system","level":1,"score":0.0489906370639801},{"id":"https://openalex.org/C111472728","wikidata":"https://www.wikidata.org/wiki/Q9471","display_name":"Epistemology","level":1,"score":0.0},{"id":"https://openalex.org/C138885662","wikidata":"https://www.wikidata.org/wiki/Q5891","display_name":"Philosophy","level":0,"score":0.0}],"mesh":[{"descriptor_ui":"D003430","descriptor_name":"Cross-Sectional Studies","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D003430","descriptor_name":"Cross-Sectional Studies","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D003430","descriptor_name":"Cross-Sectional Studies","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D004282","descriptor_name":"Documentation","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D004282","descriptor_name":"Documentation","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D004282","descriptor_name":"Documentation","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D006761","descriptor_name":"Hospitals","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006761","descriptor_name":"Hospitals","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006761","descriptor_name":"Hospitals","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D010820","descriptor_name":"Physicians","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D010820","descriptor_name":"Physicians","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D010820","descriptor_name":"Physicians","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D057286","descriptor_name":"Electronic Health Records","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D057286","descriptor_name":"Electronic Health Records","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D057286","descriptor_name":"Electronic Health Records","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false}],"locations_count":2,"locations":[{"id":"doi:10.3233/shti200228","is_oa":true,"landing_page_url":"https://doi.org/10.3233/shti200228","pdf_url":null,"source":{"id":"https://openalex.org/S4210179765","display_name":"Studies in health technology and informatics","issn_l":"0926-9630","issn":["0926-9630","1879-8365"],"is_oa":false,"is_in_doaj":false,"is_core":true,"host_organization":"https://openalex.org/P4310318577","host_organization_name":"IOS Press","host_organization_lineage":["https://openalex.org/P4310318577"],"host_organization_lineage_names":["IOS Press"],"type":"book series"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in Health Technology and Informatics","raw_type":"book-chapter"},{"id":"pmid:32570451","is_oa":false,"landing_page_url":"https://pubmed.ncbi.nlm.nih.gov/32570451","pdf_url":null,"source":{"id":"https://openalex.org/S4306525036","display_name":"PubMed","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"host_organization":"https://openalex.org/I1299303238","host_organization_name":"National Institutes of Health","host_organization_lineage":["https://openalex.org/I1299303238"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in health technology and informatics","raw_type":null}],"best_oa_location":{"id":"doi:10.3233/shti200228","is_oa":true,"landing_page_url":"https://doi.org/10.3233/shti200228","pdf_url":null,"source":{"id":"https://openalex.org/S4210179765","display_name":"Studies in health technology and informatics","issn_l":"0926-9630","issn":["0926-9630","1879-8365"],"is_oa":false,"is_in_doaj":false,"is_core":true,"host_organization":"https://openalex.org/P4310318577","host_organization_name":"IOS Press","host_organization_lineage":["https://openalex.org/P4310318577"],"host_organization_lineage_names":["IOS Press"],"type":"book series"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Studies in Health Technology and Informatics","raw_type":"book-chapter"},"sustainable_development_goals":[{"score":0.8500000238418579,"id":"https://metadata.un.org/sdg/4","display_name":"Quality Education"}],"awards":[],"funders":[],"has_content":{"pdf":false,"grobid_xml":false},"content_urls":null,"referenced_works_count":0,"referenced_works":[],"related_works":["https://openalex.org/W4391375266","https://openalex.org/W2748952813","https://openalex.org/W2618286804","https://openalex.org/W2329643025","https://openalex.org/W2002770077","https://openalex.org/W3131163342","https://openalex.org/W2092256833","https://openalex.org/W2142369114","https://openalex.org/W2361728394","https://openalex.org/W2166271660"],"abstract_inverted_index":{"INTRODUCTION:":[0],"There":[1],"are":[2,11],"factors":[3],"inherent":[4],"in":[5,71,220],"Health":[6,130,238],"Information":[7],"Systems":[8],"that,":[9],"when":[10,234],"used":[12],"improperly,":[13],"can":[14],"degrade":[15],"the":[16,19,27,35,46,53,61,64,72,82,135,138,142,193,198,202,236],"quality":[17,47,65,140,163,191,223],"of":[18,29,34,40,48,66,74,79,85,95,137,141,164,192,209,212,222],"information,":[20],"which":[21],"may":[22],"imply,":[23],"among":[24],"other":[25],"things,":[26],"lack":[28],"integrity,":[30],"inconsistency":[31],"or":[32],"inaccuracy":[33],"information.":[36],"OBJECTIVE:":[37],"The":[38,77,161,190,207],"aim":[39],"this":[41,210],"study":[42],"is":[43,214],"to":[44,99],"describe":[45],"electronic":[49],"clinical":[50,86,194,227],"notes":[51,91,144,166],"using":[52,122,201],"PDQI-9":[54,75,203],"score":[55,204],"(Spanish":[56],"version).":[57],"METHODS:":[58],"We":[59],"evaluated":[60,196],"judgment":[62],"on":[63],"two":[67],"medical":[68],"auditors":[69],"trained":[70,199],"use":[73],"tool.":[76],"unit":[78],"analysis":[80],"was":[81,205],"3":[83],"types":[84],"notes:":[87],"admission":[88,143],"notes,":[89],"progress":[90,165],"and":[92,113,148,167,179],"discharge":[93,168],"summaries":[94,169],"adult":[96],"patients":[97],"admitted":[98],"general":[100],"wards.":[101],"Sampling":[102],"type:":[103],"random.":[104],"STATISTICAL":[105],"ANALYSIS:":[106],"continuous":[107],"variables":[108],"were":[109,120,133,145,170],"summarized":[110],"with":[111],"median":[112,136],"interquartile":[114],"range.":[115],"Medians":[116],"between":[117],"2":[118],"reviewers":[119,200],"compared":[121],"Mann":[123],"Whitney":[124],"hypothesis":[125],"test.":[126],"RESULTS:":[127],"120":[128],"Electronic":[129,237],"Record":[131],"(EHR)":[132],"selected,":[134],"overall":[139,162],"33":[146,180,183],"(31-34)":[147],"32":[149],"(32-37)":[150],"for":[151,216],"each":[152],"reviewer":[153],"respectively,":[154],"without":[155],"any":[156],"statistically":[157],"significant":[158],"differences":[159],"(p=0.729).":[160],"28":[171],"(27-33)":[172],"vs":[173,182],"27":[174],"(27-32),":[175],"p":[176,185],"=":[177,186],"0.175":[178],"(32-34)":[181],"(31-34),":[184],"0.243,":[187],"respectively.":[188],"CONCLUSIONS:":[189],"documents":[195],"by":[197],"good.":[206],"application":[208],"type":[211],"tool":[213],"valuable":[215],"making":[217],"a":[218],"diagnosis":[219],"terms":[221],"that":[224],"allows":[225],"improving":[226],"documentation,":[228],"as":[229,231],"well":[230],"peer":[232],"communication":[233],"reading":[235],"Record.":[239]},"counts_by_year":[{"year":2026,"cited_by_count":1}],"updated_date":"2026-07-01T08:55:40.977307","created_date":"2025-10-10T00:00:00"}
