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The effectiveness of a bundled intervention to improve resident progress notes in an electronic health record
Author(s) -
Dean Shan M.,
Eickhoff Jens C.,
Bakel Leigh Anne
Publication year - 2015
Publication title -
journal of hospital medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.128
H-Index - 65
eISSN - 1553-5606
pISSN - 1553-5592
DOI - 10.1002/jhm.2283
Subject(s) - medicine , audit , intraclass correlation , documentation , confidence interval , quality management , electronic health record , intervention (counseling) , reliability (semiconductor) , health records , family medicine , health care , medical physics , nursing , operations management , computer science , clinical psychology , management system , power (physics) , physics , management , quantum mechanics , economics , programming language , economic growth , psychometrics
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