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 language | English (US) |
|---|---|
| Pages (from-to) | 653-659 |
| Number of pages | 7 |
| Journal | Applied Clinical Informatics |
| Volume | 7 |
| Issue number | 3 |
| DOIs | |
| State | Published - 2016 |
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Keywords
- Clinical documentation
- Electronic health record
- Medical education
ASJC Scopus subject areas
- Computer Science Applications
- Health Informatics
- Health Information Management
Cite this
Duly noted : Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record. / Fanucchi, Laura; Yan, Donglin; Conigliaro, Rosemarie L.
In: Applied Clinical Informatics, Vol. 7, No. 3, 2016, p. 653-659.Research output: Contribution to journal › Article
}
TY - JOUR
T1 - Duly noted
T2 - Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record
AU - Fanucchi, Laura
AU - Yan, Donglin
AU - Conigliaro, Rosemarie L.
PY - 2016
Y1 - 2016
N2 - 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.
AB - 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.
KW - Clinical documentation
KW - Electronic health record
KW - Medical education
UR - http://www.scopus.com/inward/record.url?scp=84979031887&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84979031887&partnerID=8YFLogxK
U2 - 10.4338/ACI-2016-02-CR-0025
DO - 10.4338/ACI-2016-02-CR-0025
M3 - Article
VL - 7
SP - 653
EP - 659
JO - Applied Clinical Informatics
JF - Applied Clinical Informatics
SN - 1869-0327
IS - 3
ER -