The effectiveness of a bundled intervention to improve resident progress notes in an electronic health record

Providers nationally have observed a decline in the quality of documentation after implementing electronic health records (EHRs). In this pilot study, we examined the effectiveness of an intervention bundle designed to improve resident progress notes written in an EHR and to establish the reliabilit...

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Bibliographic Details
Published in:Journal of hospital medicine 2015-02, Vol.10 (2), p.104-107
Main Authors: Dean, Shannon M., Eickhoff, Jens C., Bakel, Leigh Anne
Format: Article
Language:English
Subjects:
Advisory Committees
Electronic Health Records - standards
Female
Humans
Internship and Residency - methods
Internship and Residency - standards
Male
Physicians - standards
Pilot Projects
Retrospective Studies
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Summary:Providers nationally have observed a decline in the quality of documentation after implementing electronic health records (EHRs). In this pilot study, we examined the effectiveness of an intervention bundle designed to improve resident progress notes written in an EHR and to establish the reliability of an audit tool used to evaluate notes. The bundle consisted of establishing note‐writing guidelines, developing an aligned note template, and educating interns about the guidelines and using the template. Twenty‐five progress notes written by pediatric interns before and after this intervention were examined using an audit tool. Reliability of the tool was evaluated using the intraclass correlation coefficient (ICC). The total score of the audit tool was summarized in terms of means and standard deviation. Individual item responses were summarized using percentages and compared between the pre‐ and postintervention assessment using the Fisher exact test. The ICC for the audit tool was 0.96 (95% confidence interval: 0.91–0.98). A significant improvement in the total note score and in questions related to note clutter was seen. No significant improvement was seen for questions related to copy‐paste. The study suggests that an intervention bundle can lead to some improvements in note writing. Journal of Hospital Medicine 2015;10:104–107. © 2014 Society of Hospital Medicine
ISSN:1553-5592
1553-5606
DOI:10.1002/jhm.2283