Content validation of drug problem-oriented clinical record

Abstract

Background

Worldwide, hospitals are responsible for restoring health. However, poorly executed processes in these institutions can lead to risks and harm to patients, especially in identifying drug related problems. This fact justifies the proposal of tools to support the diagnosis, management and resolution of these problems.

Objective

To develop and content validate a clinical record that is oriented towards drug-related problems.

Method

A drug-oriented clinical record was first developed, after which it underwent content validation. The study was carried out between September and December 2017.7 The first version of the drug-related clinical record was prepared by two experienced researchers, using studies and problem-oriented medical tools described in the literature. Thereafter, content validation was performed using the nominal group technique. The expert panel consisted of a physician, two nurses, and three pharmacists with clinical experience in a hospital setting or pharmaceutical care. After that, the respective instrument was assessed according to the criteria objectivity, simplicity, clarity, relevance. These criteria are intended to ensure the rigor and reliability of instrument content.

Results

Experts’ suggestions included modification of the order of some items, insertion of new items, modification of item-writing procedures, expansion of specific fields, and better specification of data that is to be filled in as an item. The final version of the instrument was titled “DAM Clinical Record” (Diagnostics - Adverse Clinical Findings - Medicines) and comprised 45 items categorized into six sections: Patient Identification, Anamnesis, Clinical Diagnosis, Adverse Clinical Findings, Medicines and Pharmaceutical Evaluation.

Conclusion

A clinical record oriented towards drug-related problems, named DAM, was developed to guide healthcare professionals in identifying and solving drug-related problems. All relevant information generated in the hospital setting was consecutively stored as drug problem-oriented clinical records after undergoing thorough content validation.