Appl Clin Inform 2016; 07(03): 653-659
DOI: 10.4338/ACI-2016-02-CR-0025
Case Report
Schattauer GmbH

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

Laura Fanucchi
1  Center for Health Services Research, University of Kentucky College of Medicine, Lexington, KY
,
Donglin Yan
2  University of Kentucky College of Public Health, Lexington, KY
,
Rosemarie L. Conigliaro
3  Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
› Author Affiliations
Funding Funding The authors report no external funding source for this study.
Further Information

Publication History

received: 29 February 2016

accepted: 09 May 2016

Publication Date:
19 December 2017 (online)

Summary

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.

Citation: Fanucchi L, Yan D, Conigliaro RL. Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record.