This was a qualitative study that included the investigation of information adequacy and also development, validation, and evaluation of a model to produce structured clinical morning reports conducted at the department of Obstetrics and Gynecology of three teaching hospitals in north-eastern Iran. This structured report is developed in two separate formats. The study was conducted in three phases, as follow.
Phase I: Studying current status of MR documentations
In the first phase, a survey was conducted to examine the current quality of MR documentations in the participating hospitals. For this purpose, a checklist was developed in two sections with a focus on the structure and documentation of clinical MR sessions, borrowing items from previous studies (5,10,11), followed by an expert-panel check and verification step (Table 1. Shows the characteristics of the participating experts: C01, C02). The initially developed checklist was completed by three gynecologists and obstetricians in charge of MR session management at the time of research conduction in the three mentioned hospitals.
Table 1. The Expert-panel characteristics with identification codes
A total of 120 MR reports were selected based on random sampling among the currently available reports within the report archive. All reports were in “free-text” format. Every report was thoroughly read and analyzed in order to extract informational items.
In the next stage, the list of extracted items was provided to the four members of the panel (Table 1. Involved experts: C01, C02, C03, C04). After reviewing by the panel, all extracted items were approved and subsequently classified into four thematic categories. The pre-approved list of items and categories were then shared for two rounds of enhancement and approval a modified Delphi technique as follow:
A) In the first round, all final items were assessed by ten clinical experts from the participating hospitals, none was part of the expert panel. Table 2 shows general characteristics of the experts who participated in the Delphi study. Each item was allowed to be tagged for removal or to be kept based on the agreement quotient. Accordingly, the items with greater than 75% agreement quotient were kept in the first round and were not passed to the second round. The items with 50% to 75% agreement quotient were reassessed in the second round; and items with an agreement quotient of below 50% were omitted. After the end of the first round, all extracted items obtained more than 75% agreement quotient. However, new items were also suggested by experts.
B) In the second round, clinical experts were requested to score the value of each item. Accordingly, the Likert Scale was used in a discrete and typical format of an interval scale, ranging from one (strongly disagree) to five (strongly agree). Then, the mean and standard deviation (SD) of scores for each item were calculated, and then a cut-off point was selected. The mean scores below this point were those items that were to be removed from the list.
Table 2. General information about the experts who participated in the items validation stage
Phase II: Developing a Structured Model for Clinical Morning Reports
In this phase, a structured model of clinical MR was developed based on the previously validated items. This model was created in two formats: structured paper-based form (SPF) and structured electronic format (SEF).
The SPF format was developed in two parts: general and specific. In the first part, based on the opinions of the two expert panel members (Table 1. Involved experts: C01, C02), the general information items for report forms were added. The specific part included all confirmed items from the Delphi technique, like general patient information, pregnancy details information, disease background, surgical history, midwifery history, drug use history, previous hospitalization, signs and symptoms, lab information, ultrasound data, as well as an attachment option for clinical images (shown in Table 3).
In order to create the SEF format, an electronic version of the SPF was produced using a Windows-based software built using Microsoft Visual Studio 2010. Additionally, we built an MR SEF archive using Microsoft SQL Server 2008 Database and Stimulsoft Reports 2010 software.
Table 3. The obtained items from the validation stage for using in the structured clinical morning report
General Report’s Information
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General Patient Information
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Previous Obstetric History
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Disease Background
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Surgical History
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On-call physician name
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Number of clinic visits
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First name and last name
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Admission date
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Admission time
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Gestational age
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Diabetes
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Uterus
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Number of hospitalized patients
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Number of NVD
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Age
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Prenatal care
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LMP
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Root of delivery
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BP
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Ovarian
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Number of CS
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Curettage number
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EDC
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Marriage family relation
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Unwanted pregnancy
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Pregnancy type
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CVD
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Others
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Vacuum number
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Laparotomy number
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Pregnancy by medicine
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MG
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PG
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Date
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Renal disease
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VBAC number
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Residents name
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Ab
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LC
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DC
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Comments
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Drug addiction
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EP
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Estimation of gestational age by LMP
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Estimation of gestational age by ultrasound
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Smoking
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CC
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Current situation
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Others
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Midwifery History
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Drug Use History
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Previous Hospitalization
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Signs and Symptoms
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Lab Information
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Ultrasound Data
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Others
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Infertility
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Drug name (Generic)
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Date
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AF
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Date
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Date
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Disease progress
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Curettage
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Duration of use
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Cause
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BP
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Time
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Actual gestational age
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Final diagnosis
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Stillbirth
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Drug dosage
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Therapeutic care
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FHR
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Test name
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The present of gestational age
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Diagnostic measures
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Repeated abortion
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Discontinuation date
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FH
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Amniotic fluid index
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Therapeutic measures
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Others
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Reason for Discontinuation
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VB
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Placenta position
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T
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Comments
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RR
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PR
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TV
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NVD: Normal Vaginal Delivery, CS: Cesarean Section, LMP: Last Menstrual Period, EDC: Estimated Date Of Confinement, MG: Multigravida, PG: Prim gravida, Ab: Abortion, LC: Living Children, DC: Dead Children, EP: Ectopic Pregnancy, CC: Chief Complaint, BP: Blood Pressure, CVD: Cardiovascular Disease, AF: Amniotic Fluid, FHR: Fetal Heart Rate, FH: Fundal Height, VB: Vaginal Bleeding, T: Temperature, RR: Respiratory Rate, PR: Pulse Rate, TV: Test of Vagina
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The face and content validity of the developed structured forms were checked by three members of the expert panel (Table 1. Involved experts: C01, C02, C03). As a result, some item classes were revised and some items of the initial form were merged, splitted or replaced.
Phase III: Evaluation of the proposed model
In order to evaluate the quality of proposed structure model, a questionnaire was designed consisted of two sections. Section 1 was aimed at measuring the adequacy of the finally selected items, and Section 2 was focused on the comparisonal assessment between the three clinical MR formats (conventional, SPF, and SEF), in terms of readability, clarity of patient status, ease of reporting, future research application, ease of archiving and retrieval, and preference for use. Both sections were using independent questions. The questionnaire was initially provided to the expert-panel members (Table 1. Involved experts: C03, C04, C05) for review and approval.
A total of 16 MR documents were selected based on the opinions of the consulting experts containing different scenarios. Afterward, the reports older than three months were taken into consideration.
To prepare the three formats, the same residents in charge of the original report were asked to produce the SPF format for the same patients. Later, the SEF format of each report was produced by the research team using the completed SPF content.
For final evaluation, all three formats, including the SPF, SEF, and the conventional formats were shared with the selected experts for comparison and evaluation. Overall, sixteen MR documents in three formats (n=48) were provided to 20 residents of Obstetrics and Gynecology (excluding those who participated in previous tasks) along with the questionnaire. Excel 2010 was used for the analysis of the results.