Improved Documentation of Wound Care With a Structured Encounter Form in the Pediatric Emergency Department
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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Cited by (19)
Evaluation methods for the assessment of acute care nurse practitioner inserted central lines: Evidence-based strategies for practice
2011, JAVA - Journal of the Association for Vascular AccessCitation Excerpt :Chart audits were used to gather data both before and after the standardized forms were initiated in each of the studies; a total of 2,780 charts were reviewed in these three studies. An overall improvement of 12% (N = 200, p<0.001) in chart completeness of wound care documentation was found in one study[21], while an improvement of 49% (N = 175, p<0.001) with national acute asthma treatment guideline compliance was demonstrated in another.[22] Overall improvement scores were not calculated in a third study,[23] but improvement among nineteen (19) documentation variables was found to be statistically significant with a p<0.001 (N = 2405).
Improving information adequacy of clinical morning reports; development of a structured model in the obstetrics and gynecology department
2021, Health Education and Health PromotionElectronic medical record error in reported time of discharge: A prospective analysis at a tertiary care hospital
2021, International Journal of Healthcare ManagementOrthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentation for Pediatric Supracondylar Humerus Fractures
2019, Journal of the American Academy of Orthopaedic Surgeons
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.