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

2016 ◽  
Vol 07 (03) ◽  
pp. 653-659 ◽  
Author(s):  
Donglin Yan ◽  
Rosemarie Conigliaro ◽  
Laura Fanucchi
Keyword(s):  
Quality Improvement ◽  
Electronic Health Record ◽  
Albert Einstein College ◽  
Quality Improvement Project ◽  
Health Record ◽  
Clinical Documentation ◽  
Improvement Project ◽  
Significant Difference ◽  
Electronic Health

SummaryCommunication 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.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).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.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.

scholarly journals Improving patient portal enrolment in an academic resident continuity clinic: quality improvement made simple

2019 ◽  
Vol 8 (2) ◽  
pp. e000430 ◽  
Author(s):  
Courtney Rhudy ◽  
Jane Broxterman ◽  
Sara Stewart ◽  
Victoria Weaver ◽  
Cheryl Gibson ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Electronic Health Record ◽  
Quality Improvement Project ◽  
Management Tool ◽  
Portal System ◽  
Nursing Workload ◽  
Health Record ◽  
Patient Portal ◽  
Improvement Project ◽  
Electronic Health

Electronic health record patient portal usage has been associated with improvement in chronic disease parameters, patient functional status and patient satisfaction. Our institution’s patient portal is a secure, online health management tool that connects patients to portions of their electronic health record.Our quality improvement project aimed to increase patient portal enrolment significantly in our Internal Medicine resident patient panels.This study was conducted in a large, multisite health system in Kansas City, Kansas that serves a diverse patient population. Our clinic includes 65 resident patient panels. We followed a subset of 16 resident patient panels in this quality improvement project. A baseline audit showed that 35% of the 1628 patients in these panels were enrolled in the patient portal system. A standardised, nurse-initiated portal sign-up process following patient rooming was implemented. Initial results indicated a 9.6% increase in patient portal sign-up at the end of the first 4-week cycle. We then implemented educational sessions for our clinic nurses as well as attending physicians, and achieved a 15.1% increase from baseline to the end of the second 4-week cycle, resulting in 86 patient portal activations (p<0.01).Resident physicians worked with clinic nurse partners in two formats for this project. Nurses assigned to patient rooming for residents during the clinic sessions being studied (rooming nurses) initiated the portal sign-up process. Nurses assigned to partner with the resident for longitudinal patient care management, anchor nurses, worked with residents on items such as phone messages or portal messages. Semi-structured interviews of the four anchor nurses aligned with the 16 residents were conducted at the end of the study and revealed that nursing staff perceived increased patient portal activity to be associated with a decrease in nursing workload and an increase in patient engagement.

Transforming Data From Information to Quality Improvement: A Panel Discussion With Electronic Health Record Vendors

2015 ◽  
Vol 11 (3) ◽  
pp. 174-175 ◽  
Author(s):  
Douglas W. Blayney
Keyword(s):  
Quality Improvement ◽  
Electronic Health Record ◽  
Cancer Care ◽  
Panel Discussion ◽  
Health Record ◽  
Electronic Health

This session explores the approaches taken by various electronic health record vendors to measuring and improving the quality of cancer care.

scholarly journals Practice Facilitator Strategies for Addressing Electronic Health Record Data Challenges for Quality Improvement: EvidenceNOW

2018 ◽  
Vol 31 (3) ◽  
pp. 398-409 ◽  
Author(s):  
Jennifer R. Hemler ◽  
Jennifer D. Hall ◽  
Raja A. Cholan ◽  
Benjamin F. Crabtree ◽  
Laura J. Damschroder ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Electronic Health Record ◽  
Health Record ◽  
Electronic Health Record Data ◽  
Record Data ◽  
Electronic Health

P3-281: UNSTRUCTURED CLINICAL DOCUMENTATION DESCRIBING SYMPTOMS OF COGNITIVE IMPAIRMENT IN THE ELECTRONIC HEALTH RECORD

2006 ◽  
Vol 14 (7S_Part_22) ◽  
pp. P1186-P1186
Author(s):  
Andrea L. Gilmore-Bykovskyi ◽  
Laura M. Block ◽  
Lily Walljasper ◽  
Nikki L. Hill ◽  
Carey E. Gleason ◽  
...  
Keyword(s):  
Cognitive Impairment ◽  
Electronic Health Record ◽  
Health Record ◽  
Clinical Documentation ◽  
Electronic Health

scholarly journals Assessing the practice of written referrals to neuroradiology and how this process can be improved and standardised

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S181-S182
Author(s):  
Fraser Currie ◽  
Rashi Negi ◽  
Hari Shanmugaratnam
Keyword(s):  
Quality Improvement ◽  
Scoring Systems ◽  
Quality Improvement Project ◽  
Cortical Atrophy ◽  
Secondary Outcome ◽  
Quality Improvement Initiative ◽  
Exclusion Criteria ◽  
Quality Of Information ◽  
Improvement Project

AimsThis quality improvement project aims to improve the quality of information provided in the referrals from the older adult psychiatry department to radiology when requesting neuroradiological imaging.The secondary outcome aims to standardise information on the referral proforma. We hypothesise that this improved referral proforma will lead to improved quality of reporting from the radiology department, which will form the second stage of this quality improvement project.A further area of interest of this exercise is to establish whether standardised radiological scoring systems are requested in the referral, as these can be utilised as a means to standardise reported information.MethodRetrospective electronic case analysis was performed on 50 consecutive radiology referrals for a period of 3 months from November 2019 to January 2020. Data were obtained from generic MRI and CT referral proforma and entered into a specifically designed data collection tool. Recorded were patient demographics, provisional diagnosis, modality of imaging, use of ACE-III cognitive score, radiological scoring systems, and inclusion and exclusion criteria.ResultResults from 50 referrals have shown: 60% were male, 40% female. Average patient age of 74, ranging from 49 to 95. 58% were referred for CT head with 42% for MRI head. More than half of referrals quoted the ACE-III score. 26% of referrals stated exclusion criteria such as space occupying lesions, haemorrhages or infarcts. 10% of referrals requested specific neuro-radiological scoring scales. Specific scales which were requested included GCA (global cortical atrophy), MTA scale (medial temporal atrophy), Koedam scale (evidence of parietal atrophy) and Fazekas (evidence of vascular changes). Only 80% of referrals included the patients GP details on the referral form.Conclusion1. This quality improvement initiative has highlighted that the current level of information in referring patient to radiology is variable and dependent on the referrer.2. All referrals should state exclusion criteria as per the NICE guidelines on neuroimaging in diagnosis of dementia.3. Preliminary evidence suggests that requesting specific radiological rating scales could improve the quality of information received in the imaging report. The second part of this quality improvement initiative will aim to explore the impact of requesting these scales routinely.

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