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

Content Provider	Europe PMC
Author	Fanucchi, Laura Yan, Donglin Conigliaro, Rosemarie L.
Copyright Year	2016
Abstract	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.
Related Links	https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC5052539&blobtype=pdf
Page Count	7
Volume Number	7
PubMed Central reference number	PMC5052539
Issue Number	3
PubMed reference number	27452895
Journal	Applied Clinical Informatics [Appl Clin Inform]
e-ISSN	18690327
DOI	10.4338/aci-2016-02-cr-0025
Language	English
Publisher	Schattauer
Publisher Date	2016-07-06
Access Restriction	Open
Rights License	© Copyright Schattauer 2016
Subject Keyword	Electronic health record clinical documentation medical education
Content Type	Text
Resource Type	Article
Subject	Computer Science Applications Health Informatics Health Information Management