Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research

Perceptions of Portuguese medical coders on the transition to ICD-10-CM/PCS: A national survey

BACKGROUND

In Portugal, trained physicians undertake the clinical coding process, which serves as the basis for hospital reimbursement systems. In 2017, the classification version used for coding of diagnoses and procedures for hospital morbidity changed from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS).

OBJECTIVE

To assess the perceptions of medical coders on the transition of the clinical coding process from ICD-9-CM to ICD-10-CM/PCS in terms of its impact on data quality, as well as the major differences, advantages, and problems they faced.

METHOD

We conducted an observational study using a web-based survey submitted to medical coders in Portugal. Survey questions were based on a literature review and from previous focus group studies.

RESULTS

A total of 103 responses were obtained from medical coders with experience in the two versions of the classification system (i.e. ICD-9-CM and ICD-10-CM/PCS). Of these, 82 (79.6%) medical coders preferred the latest version and 76 (73.8%) considered that ICD-10-CM/PCS guaranteed higher quality of the coded data. However, more than half of the respondents (N = 61; 59.2%) believed that more time for the coding process for each episode was needed.

CONCLUSION

Quality of clinical coded data is one of the major priorities that must be ensured. According to the medical coders, the use of ICD-10-CM/PCS appeared to achieve higher quality coded data, but also increased the effort.

IMPLICATIONS

According to medical coders, the change off classification systems should improve the quality of coded data. Nevertheless, the extra time invested in this process might also pose a problem in the future.

A Hospital Medical Record Quality Scoring Tool (MeReQ): Development, Validation, and Results of a Pilot Study

Hospital medical records are valuable and cost-effective documents for assessing the quality of healthcare provided to patients by a healthcare facility during hospitalization. However, there is a lack of internationally validated tools that measure the quality of the whole hospital medical record in terms of both form and content. In this study, we developed and validated a tool, named MeReQ (medical record quality) tool, which quantifies the quality of the hospital medical record and enables statistical modeling using the data obtained. The tool was applied to evaluate a sample of hospital individual patient medical records from a secondary referral hospital and to identify the departments that require quality improvement interventions and the effects of improvement actions already implemented.

An evaluation of staff experiences of the Royal Literary Fund writer-in-residence service to support improvements in written communication in healthcare

Written communication is essential to staff and patient experience in healthcare. The Royal Literary Fund has hosted a writing fellow in an NHS Trust since 2018 providing professional writing training. The aim of this evaluation was to explore the experiences of staff using the service. Semi-structured interviews were conducted with 21 staff members from a range of professions who had accessed the service. Data were analysed using thematic analysis. Findings: The writing service was highly valued. Three themes emerged: feelings about writing at work, reported benefits of attending sessions, and perceived barriers to accessing them. Staff felt underskilled in professional writing and described the wish to write more succinctly and reflectively. Self-reported confidence increased after sessions. Stigma around writing skills prevented some staff from recommending the service. Wider adoption of professional writing skills training through the NHS could have benefits in terms of increasing self-perceived skills and confidence.

Assessing the Assessment-Developing and Deploying a Novel Tool for Evaluating Clinical Notes' Diagnostic Assessment Quality

BACKGROUND

Ambulatory diagnostic errors are increasingly being recognized as an important quality and safety issue, and while measures of diagnostic quality have been sought, tools to evaluate diagnostic assessments in the medical record are lacking.

OBJECTIVE

To develop and test a tool to measure diagnostic assessment note quality in primary care urgent encounters and identify common elements and areas for improvement in diagnostic assessment.

DESIGN

Retrospective chart review of urgent care encounters at an urban academic setting.

PARTICIPANTS

Primary care physicians.

MAIN MEASURES

The Assessing the Assessment (ATA) instrument was evaluated for inter-rater reliability, internal consistency, and findings from its application to EHR notes.

KEY RESULTS

ATA had reasonable performance characteristics (kappa 0.63, overall Cronbach's alpha 0.76). Variability in diagnostic assessment was seen in several domains. Two components of situational awareness tended to be well-documented ("Don't miss diagnoses" present in 84% of charts, red flag symptoms in 87%), while Psychosocial context was present only 18% of the time.

CONCLUSIONS

The ATA tool is a promising framework for assessing and identifying areas for improvement in diagnostic assessments documented in clinical encounters.

Clinical documentation requirements for the accurate coding of hospital-acquired urinary tract infections in Australia

Aims We evaluated the accuracy of medical coders in distinguishing the aetiology of urinary tract infection according to clinical documentation. Methods The clinical documentation of patients coded as having had a hospital-acquired urinary tract infection from January to June 2020 at two Melbourne hospitals were assessed for community or hospital acquisition. Results We found that 48.89% of cases were inaccurately categorised as hospital-acquired, due to insufficient detail in clinical documentation. Risk factors for hospital-acquired urinary tract infection were present in at least 30% of correctly categorised cases. Conclusions Clinical documentation is not filled out with sufficient detail or in a timely enough manner for clinical coders to distinguish between hospital or community origin.

The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study

The reuse of healthcare data for various purposes will become increasingly important in the future. To enable the reuse of clinical data, structured and standardized documentation is conditional. However, the primary purpose of clinical documentation is to support high-quality patient care. Therefore, this study investigated the effect of increased structured and standardized documentation on the quality of notes in the Electronic Health Record. A multicenter, retrospective design was used to assess the difference in note quality between 144 unstructured and 144 structured notes. Independent reviewers measured note quality by scoring the notes with the Qnote instrument. This instrument rates all note elements independently using and results in a grand mean score on a 0–100 scale. The mean quality score for unstructured notes was 64.35 (95% CI 61.30–67.35). Structured and standardized documentation improved the Qnote quality score to 77.2 (95% CI 74.18–80.21), a 12.8 point difference (p < 0.001). Furthermore, results showed that structured notes were significantly longer than unstructured notes. Nevertheless, structured notes were more clear and concise. Structured documentation led to a significant increase in note quality. Moreover, considering the benefits of structured data recording in terms of data reuse, implementing structured and standardized documentation into the EHR is recommended.

Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement

OBJECTIVE

Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework.

DESIGN AND SETTING

Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system.

METHODS

Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework.

RESULTS

Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%.

CONCLUSIONS

In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.

Evaluation of an advanced practice provider emergency department critical care step-down unit

OBJECTIVE

In response to concerns about patient care and safety, our urban, tertiary care, Level 1 trauma center adult emergency department (ED) created an advanced practice provider-staffed critical care step-down unit (CCSU). We conducted a comprehensive evaluation of the CCSU's impact on patient care, safety, and ED operations.

METHODS

We compared ED length of stay, return visits to the ED within 72 hours, billing code assignments (current procedural terminology evaluation and management [CPT E&M] codes), and quality of electronic health record documentation per QNOTE for the 2 years after the CCSU was initiated (CCSU period) versus before its initiation (pre-CCSU period).

RESULTS

There were 31,418 critical care ED patient visits in the pre-CCSU period and 33,396 in the CCSU period. Median ED length of stay did not change overall between the CCSU versus pre-CCSU period (∆1 [95% confidence interval (CI) = -2.4, 4.4] minutes), but decreased for patients who remained in the critical care suites (∆-4 [95% CI = -7.8, -0.2] minutes). 72-hour return ED visits also did not change overall (∆0% [95% CI = -0.1, 0]), but decreased for patients who remained in the critical care suites (∆0.4% [95% CI = -0.05, -0.4]). CPT E&M billing increased for highest-level visits (99,291: ∆1.3% [95% CI= 0.5, 2.0]). Quality of electronic health record documentation as measured by QNOTE also improved (∆11.5% [95% CI = 4.9, 18.1]).

CONCLUSION

This ED's CCSU performance metrics indicate at least moderate improvement in ED length of stay, 72-hour return visits, critical care patient billing, and electronic health record documentation. EDs elsewhere can consider implementation of this advanced practice provider-staffed solution to improvement in critical care in ED.

Improved efficiency of patient admission with electronic health records in neurosurgery

BACKGROUND

Electronic health records (EHRs) may be controversial but they have the potential to improve patient care. We investigated whether the introduction of an electronic template-based admission form for the collection of information about the patient's medical history and neurological and clinical state at admission in the neurosurgical unit might have an impact on the quality of documentation in a discharge record and the amount of time taken to produce this documentation.

METHOD

A new digital template-based admission form (EHR) was developed and assessed with QNOTE, an assessment tool of medical notes with standardised criteria and the possibility to benchmark the quality of documentations. This was compared to 30 prior paper-based handwritten documentations (HWD) regarding the utilisation of these medical notes for dictation of medical discharge records.

RESULTS

Implementation of the EHR significantly improved the quality of patient admission documentation with a QNOTE mean grand score of 87 ± 22 (p < 0.0001) compared to prior HWD with 44 ± 30. The mean documentation time for HWD was 8.1 min ± 4.1 min and the dictation time for discharge records was 10.6 min ± 3.5 min. After implementation of EHR, the documentation time increased slightly to 9.6 min ± 2.3 min (n.s.), while the time for dictation of discharge records was reduced to 5.1 min ± 1.2 min (p < 0.0001). There was a clear correlation between a higher quality of documentation and a higher needed documentation time as well as higher quality of documentation and lower dictation times of discharge records.

CONCLUSION

Implementation of the EHR improved the quality of patient admission documentation and reduced the dictation time of discharge records.

IMPLICATIONS

It is crucial to involve stakeholders and users of EHRs in a timely manner during the stage of development and implementation phase to ensure optimal results and better usability.

Embracing Multiple Stakeholder Perspectives in Defining Trainee Competence

PURPOSE

To explore how multiple stakeholder groups contribute to the understanding of trainee competence.

METHOD

The authors conducted a constructivist qualitative study in 2015 using focus group discussions to explore the perceptions of different stakeholder groups (patients, nurses/nurse practitioners, supervisors/senior physicians, leaders/administrators, trainees) regarding trainee competence in the emergency department. The authors used a conventional content analysis, a comparative analysis of supervisors'/senior physicians' versus other stakeholders' perspectives, and a directed analysis informed by stakeholder theory to analyze the focus group transcripts.

RESULTS

Forty-six individuals participated in nine focus groups. Four categories of competence were identified: Core Clinical Activities, Patient Centeredness, Aligning Resources, and Code of Conduct. Stakeholders generally agreed in their overall expectations regarding trainee competence. Within individual categories, each stakeholder group identified new considerations, details, and conflicts, which were a replication, elaboration, or complication of a previously identified theme. All stakeholders stressed those aspects of trainee competence that were relevant to their work or values. Trainees were less aware of the patient perspective than that of the other stakeholder groups.

CONCLUSIONS

Considering multiple stakeholder perspectives enriched the description and conceptualization of trainee competence. It also can inform the development of curricula and assessment tools and guide learning about inter- and intradisciplinary conflicts. Further research should explore how trainees' perceptions of value are influenced by their organizational context and, in particular, how trainees adapt their learning goals in response to the divergent demands of key stakeholders.

How are allied health notes used for inpatient care and clinical decision-making? A qualitative exploration of the views of doctors, nurses and allied health professionals

BACKGROUND

Inpatient care is dependent upon the effective transfer of clinical information across multiple professions. However, documented patient clinical information generated by different professions is not always successfully transferred between them. One obstacle to successful information transfer may be the reader's perception of the information, which is framed in a particular professional context, rather than the information per se.

OBJECTIVE

The aim of this research was to investigate how different health professionals perceive allied health documentation and to investigate how clinicians of all experience levels across medicine, nursing and allied health perceive and use allied health notes to inform their decision-making and treatment of patients.

METHOD

The study used a qualitative approach. A total of 53 speech pathologists, nurses, doctors, occupational therapists, dieticians and social workers (8 males; 43 females) from an Australian regional tertiary hospital participated in eleven single discipline focus groups, conducted over 4 months in 2012. Discussions were recorded and transcribed verbatim and coded into themes by content analysis.

FINDINGS

Six themes contributing to the efficacy of clinical information transference emerged from the data: day-to-day care, patient function, discharge and discharge planning, impact of busy workloads, format and structure of allied health documentation and a holistic approach to patient care.

DISCUSSION

Other professions read and used allied health notes albeit with differences in focus and need. Readers searched for specific pieces of information to answer their own questions and professional needs, in a process akin to purposive sampling. Staff used allied health notes to explore specific aspects of patient function but did not obtain a holistic picture.

CONCLUSION

Improving both the relationship between the various health professions and interpretation of other professions' documented clinical information may reduce the frequency of communication errors, thereby improving patient care.

An electronic documentation system improves the quality of admission notes: a randomized trial

OBJECTIVE

There are concerns that structured electronic documentation systems can limit expressivity and encourage long and unreadable notes. We assessed the impact of an electronic clinical documentation system on the quality of admission notes for patients admitted to a general medical unit.

METHODS

This was a prospective randomized crossover study comparing handwritten paper notes to electronic notes on different patients by the same author, generated using a semistructured electronic admission documentation system over a 2-month period in 2014. The setting was a 4-team, 80-bed general internal medicine clinical teaching unit at a large urban academic hospital. The quality of clinical documentation was assessed using the QNOTE instrument (best possible score = 100), and word counts were assessed for free-text sections of notes.

RESULTS

Twenty-one electronic-paper note pairs (42 notes) written by 21 authors were randomly drawn from a pool of 303 eligible notes. Overall note quality was significantly higher in electronic vs paper notes (mean 90 vs 69, P < .0001). The quality of free-text subsections (History of Present Illness and Impression and Plan) was significantly higher in the electronic vs paper notes (mean 93 vs 78, P < .0001; and 89 vs 77, P = .001, respectively). The History of Present Illness subsection was significantly longer in electronic vs paper notes (mean 172.4 vs 92.4 words, P = .0001).

CONCLUSIONS

An electronic admission documentation system improved both the quality of free-text content and the overall quality of admission notes. Authors wrote more in the free-text sections of electronic documents as compared to paper versions.

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 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.

Aberrant drug-related behaviors: a qualitative analysis of medical record documentation in patients referred to an HIV/chronic pain clinic

BACKGROUND

Due to rising rates of opioid addiction and overdose among individuals on chronic opioid therapy, aberrant drug-related behaviors (ADRBs) are an important and challenging issue. Our objective was to qualitatively investigate the documentation of ADRBs in the medical record.

METHODS

Manually abstracted provider notes from an HIV primary care clinic were analyzed using content analysis methods.

RESULTS

Categories of ADRBs identified included patients requesting opioids, obtaining nonprescribed opioids, and becoming emotional about opioids. We also identified several types of provider language used when documenting ADRBs, including purely descriptive language and emotional language such as labeling, frustration, and concern, and responses such as setting conditions for opioid prescription and action-oriented language.

CONCLUSIONS

The impact of including emotional language in the medical record is unknown. Development of instruments that can be used to facilitate ADRB documentation, as well as evidence-based approaches to addressing ADRBs, is needed.

QNOTE: an instrument for measuring the quality of EHR clinical notes

BACKGROUND AND OBJECTIVE

The outpatient clinical note documents the clinician's information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole.

MATERIALS AND METHODS

Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ.

RESULTS

The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04).

CONCLUSIONS

We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.