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A multi reader, multi case study on the impact of using a simulated case generation system on the accuracy of clinical electronic medical record writing

A multi reader, multi case study on the impact of using a simulated case generation system on the accuracy of clinical electronic medical record writing

Status
Active, not recruiting
Phases
Unknown
Study type
Interventional
Source
ChiCTR
Registry ID
ChiCTR2400091394
Enrollment
Unknown
Registered
2024-10-28
Start date
2024-10-31
Completion date
Unknown
Last updated
2024-11-04

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

None

Interventions

Group B:Old system first, new system later
Group A:New system first, old system later

Sponsors

Shanghai General Hospital
Lead Sponsor

Eligibility

Sex/Gender
All
Age
18 Years to 99 Years

Inclusion criteria

Inclusion criteria: Reader: 1. Working in the ophthalmology department of Shanghai General Hospital; 2.Age over 18 years old; 3.Obtaining a Professional Physician Certificate; 4.Sign the informed consent form, have time to participate in the study, and complete the system testing and evaluation; Case: 1. Medical history of ophthalmology department of Shanghai First People's Hospital; 2.Case: The medical record includes admission records, surgical records, and discharge summary; 3.Case: Electronic medical record of cataract, glaucoma, age-related macular degeneration, diabetes retinopathy and retinal detachment;

Exclusion criteria

Exclusion criteria: Reader: 1.Unable to complete case writing; 2 Unable to use electronic medical record system; 3. Pregnant and lactating women, children, individuals with mental illnesses, and those with cognitive impairments; Case: 1. Incomplete medical record content; 2.Cataract case history excludes secondary diagnosis including glaucoma, age-related macular degeneration, diabetes retinopathy, retinal detachment and other eye diseases; 3.Glaucoma case history excludes secondary diagnosis including senile macular degeneration, diabetes retinopathy, retinal detachment and other fundus diseases; 4.Macular degeneration case history exclude that the secondary diagnosis includes diabetes retinopathy, retinal detachment, glaucoma and other fundus diseases; 5.Diabetes retinopathy case history exclude secondary diagnoses including glaucoma, age-related macular degeneration, retinal detachment and other fundus diseases; 6.Retinal detachment case history excludes secondary diagnosis including glaucoma, age-related macular degeneration, diabetes retinopathy and other fundus diseases; 7.Exclude electronic medical records that have not undergone surgery;

Design outcomes

Primary

MeasureTime frame
Completeness;

Secondary

MeasureTime frame
Correctness;Conciseness;Harmess;

Countries

China

Contacts

Public ContactYupeng Xu

Shanghai General Hospital

kevinxyp@163.com+86 15921111582

Outcome results

None listed

Source: ChiCTR (via WHO ICTRP) · Data processed: Feb 4, 2026