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

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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Keywords

Electronic health record - clinical documentation - medical education

 

 

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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.

• References

• 1 Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Critical Care Medicine 2013; 41 (02) 382-388.
• 2 Heiman HL, Rasminsky S, Bierman JA, Evans DB, Kinner KG, Stamos J, Martinovich Z, McGaghie WC. Medical students’ observations, practices, and attitudes regarding electronic health record documentation. Teaching and Learning in Medicine 2014; 26 (01) 49-55.
• 3 Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: Prevalence, benefits, risks, and best practice recommendations. Chest 2014; 145 (03) 632-638.
• 4 Sentinel Event Data - Root Causes by Event Type. The Joint Commission. 2015 http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_2004-2Q_2015.pdf Accessed October 5, 2015.
• 5 Melvin L, Connolly K, Pitre L, Dore KL, Wasi P. Improving medical students’ written communication skills: design and evaluation of an educational curriculum. Postgraduate Medical Journal 2015; 91 (1076): 303-308.
• 6 Dean SM, Eickhoff JC, Bakel LA. The effectiveness of a bundled intervention to improve resident progress notes in an electronic health record. Journal of Hospital Medicine 2015; 10 (02) 104-107.
• 7 Grogan EL, Speroff T, Deppen SA, Roumie CL, Elasy TA, Dittus RS, Rosenbloom ST, Holzman MD. Improving documentation of patient acuity level using a progress note template. Journal of the American College of Surgeons 2004; 199 (03) 468-475.
• 8 Stetson PD, Bakken S, Wrenn JO, Siegler EL. Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9). Applied Clinical Informatics 2012; 03 (02) 164-174.
• 9 Burke HB, Hoang A, Becher D, Fontelo P, Liu F, Stephens M, Pangaro LN, Sessums LL, O’Malley P, Baxi NS, Bunt CW, Capaldi VF, Chen JM, Cooper BA, Djuric DA, Hodge JA, Kane S, Magee C, Makary ZR, Mallory RM, Miller T, Saperstein A, Servey J, Gimbel RW. QNOTE: an instrument for measuring the quality of EHR clinical notes. Journal of the American Medical Informatics Association: JAMIA: the Journal of the American Medical Association 2014; 21 (05) 910-916.
• 10 Sturmberg JP, Martin CM, Katerndahl DA. Systems and complexity thinking in general practice literature: An integrative, historical narrative review. Annals of Family Medicine 2014; 12 (01) 66-74.
• 11 Watling C, Driessen E, van der Vleuten CPM, Lingard L. Learning from clinical work: the roles of learning cues and credibility judgements. Medical Education 2012; 46: 192-200.
• 12 March CA, Scholl G, Dversdal RK, Richards M, Wilson LM, Mohan V, Gold JA. Use of Electronic Health Record Simulation to Understand the Accuracy of Intern Progress Notes. Journal of Graduate Medical Education 2016; 08 (02) 237-240.
• 13 Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA: the Journal of the American Medical Association 2009; 302 (12) 1277-1283.