Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record

Laura Fanucchi, Donglin Yan, Rosemarie L. Conigliaro

Research output: Contribution to journalArticle

2 Scopus citations

Abstract

Background: Communication errors are identified as a root cause contributing to a majority of sentinel events. The clinical note is a cornerstone of physician communication, yet there are few published interventions on teaching note writing in the electronic health record (EHR). This is a prospective, two-site, quality improvement project to assess and improve the quality of clinical documentation in the EHR using a validated assessment tool. Methods: Internal Medicine (IM) residents at the University of Kentucky College of Medicine (UK) and Montefiore Medical Center/Albert Einstein College of Medicine (MMC) received one of two interventions during an inpatient ward month: either a lecture, or a lecture and individual feedback on progress notes. A third group of residents in each program served as control. Notes were evaluated with the Physician Documentation Quality Instrument 9 (PDQI-9). Results: Due to a significant difference in baseline PDQI-9 scores at MMC, the sites were not combined. Of 75 residents at the UK site, 22 were eligible, 20 (91%) enrolled, 76 notes in total were scored. Of 156 residents at MMC, 22 were eligible, 18 (82%) enrolled, 40 notes in total were scored. Note quality did not improve as measured by the PDQI-9. Conclusion: This educational quality improvement project did not improve the quality of clinical documentation as measured by the PDQI-9. This project underscores the difficulty in improving note quality. Further efforts should explore more effective educational tools to improve the quality of clinical documentation in the EHR.

Original languageEnglish (US)
Pages (from-to)653-659
Number of pages7
JournalApplied Clinical Informatics
Volume7
Issue number3
DOIs
StatePublished - 2016

Keywords

  • Clinical documentation
  • Electronic health record
  • Medical education

ASJC Scopus subject areas

  • Computer Science Applications
  • Health Informatics
  • Health Information Management

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