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

Correspondence to:

Laura Fanucchi, MD, MPH
Center for Health Services Research
Assistant Professor of Medicine
University of Kentucky College of Medicine
900 South Limestone
306B Charles T. Wethington Bldg
Lexington, KY 40536
Phone: 859-323-1982   
Fax: 859-257-2605   

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.


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Conflict of Interest Statement

The authors declare no commercial associations that may pose a conflict of interest with the submitted article.


Correspondence to:

Laura Fanucchi, MD, MPH
Center for Health Services Research
Assistant Professor of Medicine
University of Kentucky College of Medicine
900 South Limestone
306B Charles T. Wethington Bldg
Lexington, KY 40536
Phone: 859-323-1982   
Fax: 859-257-2605