Elsevier

Ambulatory Pediatrics

Volume 5, Issue 4, July–August 2005, Pages 253-257
Ambulatory Pediatrics

Improved Documentation of Wound Care With a Structured Encounter Form in the Pediatric Emergency Department

https://doi.org/10.1367/A04-196R.1Get rights and content

Objective.—Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital.

Methods.—The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care.

Results.—Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting.

Discussion.—In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.

Section snippets

METHODS

This prospective, nonrandomized study used a pre-post design to evaluate the effect of the introduction of a structured encounter form on the completeness of wound-care documentation. The study was approved by the hospital's Institutional Review Board, which waived the requirement for informed consent from patients or providers. The ED at Children's Hospital and Health Center had a yearly census of approximately 40 000 at the time of the study. Pediatric Emergency Medicine Board–certified or

RESULTS

There were 12 000 patient encounters during the data-collection periods (5.1% for lacerations). After the run-in period, the structured encounter form was used for 37% of wound-care encounters. We excluded 51 free-text and 65 structured charts because of wound repair by consultants (26), repair by method other than suture or stapling (32), completion of both of free-text and structured documents (12), primary patient management or documentation by any of the 3 attending-level investigators

DISCUSSION

Complete and accurate documentation of wound repair in the ED of a teaching children's hospital can be a challenging task. Strategies to improve wound-care documentation are important because the ED chart is the permanent record of care rendered and serves as the primary determinant of the level of care from which coding and billing entry are derived.

In our study, structured encounter forms were superior to free-text dictation in the documentation of pediatric wound care. Improvements in wound

CONCLUSION

We have demonstrated that structured encounter forms improve overall documentation in the pediatric ED, a setting not previously studied. Trainees who used the structured form demonstrated improvement, with senior-level residents benefiting the most. Despite these encouraging results, the design of the form may also harbor barriers to optimal documentation, such as excessive reliance on the check box and underdocumentation of pertinent positive and negative findings.

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This work was presented orally at the Ambulatory Pediatric Association (Region IX, X) Meeting, Carmel, Calif, February 11, 2001, and in poster format before the Ambulatory Pediatric Association Emergency Medicine Special Interest Group, Pediatric Academic Societies Annual Meeting, Baltimore, Md, April 29, 2001.

Reprints not available from the authors.

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