Using ChatGPT-4 to Create Structured Medical Notes From Audio Recordings of Physician-Patient Encounters: Comparative Study

BACKGROUND

Medical documentation plays a crucial role in clinical practice, facilitating accurate patient management and communication among health care professionals. However, inaccuracies in medical notes can lead to miscommunication and diagnostic errors. Additionally, the demands of documentation contribute to physician burnout. Although intermediaries like medical scribes and speech recognition software have been used to ease this burden, they have limitations in terms of accuracy and addressing provider-specific metrics. The integration of ambient artificial intelligence (AI)-powered solutions offers a promising way to improve documentation while fitting seamlessly into existing workflows.

OBJECTIVE

This study aims to assess the accuracy and quality of Subjective, Objective, Assessment, and Plan (SOAP) notes generated by ChatGPT-4, an AI model, using established transcripts of History and Physical Examination as the gold standard. We seek to identify potential errors and evaluate the model's performance across different categories.

METHODS

We conducted simulated patient-provider encounters representing various ambulatory specialties and transcribed the audio files. Key reportable elements were identified, and ChatGPT-4 was used to generate SOAP notes based on these transcripts. Three versions of each note were created and compared to the gold standard via chart review; errors generated from the comparison were categorized as omissions, incorrect information, or additions. We compared the accuracy of data elements across versions, transcript length, and data categories. Additionally, we assessed note quality using the Physician Documentation Quality Instrument (PDQI) scoring system.

RESULTS

Although ChatGPT-4 consistently generated SOAP-style notes, there were, on average, 23.6 errors per clinical case, with errors of omission (86%) being the most common, followed by addition errors (10.5%) and inclusion of incorrect facts (3.2%). There was significant variance between replicates of the same case, with only 52.9% of data elements reported correctly across all 3 replicates. The accuracy of data elements varied across cases, with the highest accuracy observed in the "Objective" section. Consequently, the measure of note quality, assessed by PDQI, demonstrated intra- and intercase variance. Finally, the accuracy of ChatGPT-4 was inversely correlated to both the transcript length (P=.05) and the number of scorable data elements (P=.05).

CONCLUSIONS

Our study reveals substantial variability in errors, accuracy, and note quality generated by ChatGPT-4. Errors were not limited to specific sections, and the inconsistency in error types across replicates complicated predictability. Transcript length and data complexity were inversely correlated with note accuracy, raising concerns about the model's effectiveness in handling complex medical cases. The quality and reliability of clinical notes produced by ChatGPT-4 do not meet the standards required for clinical use. Although AI holds promise in health care, caution should be exercised before widespread adoption. Further research is needed to address accuracy, variability, and potential errors. ChatGPT-4, while valuable in various applications, should not be considered a safe alternative to human-generated clinical documentation at this time.

Automating sedation state assessments using natural language processing

INTRODUCTION

Common goals for procedural sedation are to control pain and ensure the patient is not moving to an extent that is impeding safe progress or completion of the procedure. Clinicians perform regular assessments of the adequacy of procedural sedation in accordance with these goals to inform their decision-making around sedation titration and also for documentation of the care provided. Natural language processing could be applied to real-time transcriptions of audio recordings made during procedures in order to classify sedation states that involve movement and pain, which could then be integrated into clinical documentation systems. The aim of this study was to determine whether natural language processing algorithms will work with sufficient accuracy to detect sedation states during procedural sedation.

DESIGN

A prospective observational study was conducted.

METHODS

Audio recordings from consenting participants undergoing elective procedures performed in the interventional radiology suite at a large academic hospital were transcribed using an automated speech recognition model. Sentences of transcribed text were used to train and evaluate several different NLP pipelines for a text classification task. The NLP pipelines we evaluated included a simple Bag-of-Words (BOW) model, an ensemble architecture combining a linear BOW model and a "token-to-vector" (Tok2Vec) component, and a transformer-based architecture using the RoBERTa pre-trained model.

RESULTS

A total of 15,936 sentences from transcriptions of 82 procedures was included in the analysis. The RoBERTa model achieved the highest performance among the three models with an area under the ROC curve (AUC-ROC) of 0.97, an F1 score of 0.87, a precision of 0.86, and a recall of 0.89. The Ensemble model showed a similarly high AUC-ROC of 0.96, but lower F1 score of 0.79, precision of 0.83, and recall of 0.77. The BOW approach achieved an AUC-ROC of 0.97 and the F1 score was 0.7, precision was 0.83 and recall was 0.66.

CONCLUSION

The transformer-based architecture using the RoBERTa pre-trained model achieved the best classification performance. Further research is required to confirm the that this natural language processing pipeline can accurately perform text classifications with real-time audio data to allow for automated sedation state assessments.

CLINICAL RELEVANCE

Automating sedation state assessments using natural language processing pipelines would allow for more timely documentation of the care received by sedated patients, and, at the same time, decrease documentation burden for clinicians. Downstream applications can also be generated from the classifications, including for example real-time visualizations of sedation state, which may facilitate improved communication of the adequacy of the sedation between clinicians, who may be performing supervision remotely. Also, accumulation of sedation state assessments from multiple procedures may reveal insights into the efficacy of particular sedative medications or identify procedures where the current approach for sedation and analgesia is not optimal (i.e. a significant amount of time spent in "pain" or "movement" sedation states).

Writing for the role: A qualitative exploration of new graduate physiotherapists' transition to practice of clinical documentation

INTRODUCTION

Clinical documentation is an integral component of effective physiotherapy practice. Minimal research has explored how new graduate physiotherapists transition to practice of documentation.

OBJECTIVE

To understand new graduate physiotherapists' experiences and support needs for transitioning into this professional role, from the perspectives of new graduates and clinical supervisors.

METHODS

This study utilized the qualitative methodology of reflexive thematic analysis, situated within a critical realist framework and informed by Duchscher's stages of transition theory. Semi-structured interviews of 16 new graduate physiotherapists (less than two years post-graduation) and seven clinical supervisors (of new graduate physiotherapists) were subjected to inductive analysis, where codes were organized into themes and subthemes.

RESULTS

Three overarching themes were generated with associated subthemes. Variable preparedness for documentation identified that new graduates were equipped with the basics of documentation, yet challenged by unfamiliarity and complexity. Documentation practices evolve over time outlined experiences of new graduates developing a "written voice" and improving documentation efficiency. Workplace support is necessary irrespective of preparedness, discusses: i) opportunities to practice, reflect and refine skills, ii) protected time for documentation, and iii) access to templates and examples.

CONCLUSION

New graduate physiotherapists enter the workforce with variable levels of preparedness for clinical documentation, and may experience challenges when facing unfamiliar contexts and clinical complexity. Understanding expectations and engaging in opportunities to improve documentation skills were perceived as beneficial for enhancing new graduate practice of clinical documentation across workplace settings. Implications for workplace support to promote safe and effective practice of documentation are discussed.

The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis

BACKGROUND

Electronic medical records (EMR) are considered a key component of the health care system's digital transformation. The implementation of an EMR promises various improvements, for example, in the availability of information, coordination of care, or patient safety, and is required for big data analytics. To ensure those possibilities, the included documentation must be of high quality. In this matter, the most frequently described dimension of data quality is the completeness of documentation. In this regard, little is known about how and why the completeness of documentation might change after the implementation of an EMR.

OBJECTIVE

This study aims to compare the completeness of documentation in paper-based medical records and EMRs and to discuss the possible impact of an EMR on the completeness of documentation.

METHODS

A retrospective document analysis was conducted, comparing the completeness of paper-based medical records and EMRs. Data were collected before and after the implementation of an EMR on an orthopaedical ward in a German academic teaching hospital. The anonymized records represent all treated patients for a 3-week period each. Unpaired, 2-tailed t tests, chi-square tests, and relative risks were calculated to analyze and compare the mean completeness of the 2 record types in general and of 10 specific items in detail (blood pressure, body temperature, diagnosis, diet, excretions, height, pain, pulse, reanimation status, and weight). For this purpose, each of the 10 items received a dichotomous score of 1 if it was documented on the first day of patient care on the ward; otherwise, it was scored as 0.

RESULTS

The analysis consisted of 180 medical records. The average completeness was 6.25 (SD 2.15) out of 10 in the paper-based medical record, significantly rising to an average of 7.13 (SD 2.01) in the EMR (t178=-2.469; P=.01; d=-0.428). When looking at the significant changes of the 10 items in detail, the documentation of diet (P<.001), height (P<.001), and weight (P<.001) was more complete in the EMR, while the documentation of diagnosis (P<.001), excretions (P=.02), and pain (P=.008) was less complete in the EMR. The completeness remained unchanged for the documentation of pulse (P=.28), blood pressure (P=.47), body temperature (P=.497), and reanimation status (P=.73).

CONCLUSIONS

Implementing EMRs can influence the completeness of documentation, with a possible change in both increased and decreased completeness. However, the mechanisms that determine those changes are often neglected. There are mechanisms that might facilitate an improved completeness of documentation and could decrease or increase the staff's burden caused by documentation tasks. Research is needed to take advantage of these mechanisms and use them for mutual profit in the interests of all stakeholders.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023343; https://drks.de/search/de/trial/DRKS00023343.

Generative Language Models and Open Notes: Exploring the Promise and Limitations

Patients' online record access (ORA) is growing worldwide. In some countries, including the United States and Sweden, access is advanced with patients obtaining rapid access to their full records on the web including laboratory and test results, lists of prescribed medications, vaccinations, and even the very narrative reports written by clinicians (the latter, commonly referred to as "open notes"). In the United States, patient's ORA is also available in a downloadable form for use with other apps. While survey studies have shown that some patients report many benefits from ORA, there remain challenges with implementation around writing clinical documentation that patients may now read. With ORA, the functionality of the record is evolving; it is no longer only an aide memoire for doctors but also a communication tool for patients. Studies suggest that clinicians are changing how they write documentation, inviting worries about accuracy and completeness. Other concerns include work burdens; while few objective studies have examined the impact of ORA on workload, some research suggests that clinicians are spending more time writing notes and answering queries related to patients' records. Aimed at addressing some of these concerns, clinician and patient education strategies have been proposed. In this viewpoint paper, we explore these approaches and suggest another longer-term strategy: the use of generative artificial intelligence (AI) to support clinicians in documenting narrative summaries that patients will find easier to understand. Applied to narrative clinical documentation, we suggest that such approaches may significantly help preserve the accuracy of notes, strengthen writing clarity and signals of empathy and patient-centered care, and serve as a buffer against documentation work burdens. However, we also consider the current risks associated with existing generative AI. We emphasize that for this innovation to play a key role in ORA, the cocreation of clinical notes will be imperative. We also caution that clinicians will need to be supported in how to work alongside generative AI to optimize its considerable potential.

Surgeons' perspectives on operation report documentation

BACKGROUND

Operation report documentation is essential for safe patient care and team communication, yet it is often imperfect. This qualitative study aims to understand surgeons' perspectives on operation report documentation, with surgeons reviewing cleft palate repair operation reports. It aims to determine how surgeons write an operation report (in narrative and synoptic report formats) and explore the consequences of incomplete documentation on patient care.

METHODS

A qualitative semi-structured interview was conducted with cleft surgeons who were asked to consider operation reports and hypothetical clinical cases. Eight operation reports performed at one centre for cleft palate repair were randomly selected for review.

RESULTS

An operation report's purpose-patient care, complication documentation, future surgery, and research-will influence the detail documented. All cleft palate repair operation reports had important information missing. Synoptic report writing provides clearer documentation; however, narrative report writing may be a more robust communication and education tool. Surgeons described a bell-curve response in the level of training required to document an operation report-residents knew too little, fellows documented clearly, and Consultants documented briefer reports to highlight salient points.

CONCLUSIONS

An understanding of surgeons' perspectives on operation report documentation is richer after this study. Surgeons know that clear documentation is essential for patient care and a skill that must be taught to trainees; barriers may be the documentation method. The flexibility of a hybrid operation report format is necessary for surgical care.

Medical Student Note Quality on a Pediatrics Core Clerkship Differs by Service

Introduction Medical students rotate on various clinical disciplines with the same professional goal of learning medical documentation. This study investigated differences between medical student notes on inpatient general and subspecialty pediatric services by comparing note quality, length, and file time. Methods In a single-site, observational cohort study, medical students in the Core Clerkship in Pediatrics (CCP) from July 2020 to June 2021 participated in a note-writing didactic course. We compared notes from medical students completing their inpatient assignment on a general pediatric service to those who completed it on a pediatric subspecialty service. Primary outcomes were note quality measured by Physician Documentation Quality Instrument-9 (PDQI9), note length (measured by line count), and file time (measured by hours to completion since 6 AM on the morning of note initiation). Results We evaluated 84 notes from 84 medical students on the general pediatric services and 50 notes from 49 medical students on the pediatric subspecialty services. Note quality measured by PDQI9 was significantly higher for general pediatric service notes compared to pediatric subspecialty service notes (p = 0.03). General pediatric service notes were significantly shorter (p < 0.001). We found no difference in file time (p = 0.23). Conclusion Medical student notes on pediatric subspecialty services scored significantly lower in quality and were longer compared to general pediatric services, demonstrating the need for a more tailored note-writing curriculum and note template based on service.

Talking About Notes: Using a Design-Based Research Approach to Develop a Discharge Summary Template on a Geriatric Inpatient Unit

Background

Discharge summaries are important educational tools, guiding trainees in their collection and documentation of data. As geriatric competencies are integrated in medical curricula, documentation on in-patient geriatric rotations should represent the unique care and education provided, yet often follow generic templates. What content should be included in a geriatric discharge summary has not previously been explored and was the purpose of this study.

Methods

A mixed-methods, designed-based research approach was used to assess note quality on a geriatric in-patient unit and iteratively co-develop a template with examples through three phases: 1) needs assessment, 2) consensus building, and 3) template development.

Results

Sixty-eight discharge summaries were assessed by five geriatricians, with 14 gaps identified. Many of these reflected elements that were present but addressed generically without attention to the specificity required from a geriatric perspective. In response, the team developed a geriatric-specific template with explicit examples. Through the consensus process three barriers to quality notes and trainee education were identified: the chronic state of low-quality notes being accepted as the norm, time limitations due to the high volume of patients, and high volume of clinical documents.

Conclusions

The identification of gaps in geriatric discharge summaries allowed for the co-development of an instructional template and examples that goes beyond simple headings and highlights the importance of applying and documenting geriatric competencies. Although we encourage others to take up and modify the tools for trainees in their local context, more importantly, we encourage them to take up the dialogue about note quality.

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

CODEX Meets RACOON - A Concept for Collaborative Documentation of Clinical and Radiological COVID-19 Data

Within the scope of the two NUM projects CODEX and RACOON we developed a preliminary technical concept for documenting clinical and radiological COVID-19 data in a collaborative approach and its preceding findings of a requirement analysis. At first, we provide an overview of NUM and its two projects CODEX and RACOON including the GECCO data set. Furthermore, we demonstrate the foundation for the increased collaboration of both projects, which was additionally supported by a survey conducted at University Hospital Frankfurt. Based on the survey results mint Lesion™, developed by Mint Medical and used at all project sites within RACOON, was selected as the "Electronic Data Capture" (EDC) system for CODEX. Moreover, to avoid duplicate entry of GECCO data into both EDC systems, an early effort was made to consider a collaborative and efficient technical approach to reduce the workload for the medical documentalists. As a first effort we present a preliminary technical concept representing the current and possible future data workflow of CODEX and RACOON. This concept includes a software component to synchronize GECCO data sets between the two EDC systems using the HL7 FHIR standard. Our first approach of a collaborative use of an EDC system and its medical documentalists could be beneficial in combination with the presented synchronization component for all participating project sites of CODEX and RACOON with regard to an overall reduced documentation workload.

Uncovering Discrepancies in IV Vancomycin Infusion Records between Pump Logs and EHR Documentation

BACKGROUND

Infusion start time, completion time, and interruptions are the key data points needed in both area under the concentration-time curve (AUC)- and trough-based vancomycin therapeutic drug monitoring (TDM). However, little is known about the accuracy of documented times of drug infusions compared with automated recorded events in the infusion pump system. A traditional approach of direct observations of infusion practice is resource intensive and impractical to scale. We need a new methodology to leverage the infusion pump event logs to understand the prevalence of timestamp discrepancies as documented in the electronic health records (EHRs).

OBJECTIVES

We aimed to analyze timestamp discrepancies between EHR documentation (the information used for clinical decision making) and pump event logs (actual administration process) for vancomycin treatment as it may lead to suboptimal data used for therapeutic decisions.

METHODS

We used process mining to study the conformance between pump event logs and EHR data for a single hospital in the United States from July to December 2016. An algorithm was developed to link records belonging to the same infusions. We analyzed discrepancies in infusion start time, completion time, and interruptions.

RESULTS

Of the 1,858 infusions, 19.1% had infusion start time discrepancy more than ± 10 minutes. Of the 487 infusion interruptions, 2.5% lasted for more than 20 minutes before the infusion resumed. 24.2% (312 of 1,287) of 1-hour infusions and 32% (114 of 359) of 2-hour infusions had over 10-minute completion time discrepancy. We believe those discrepancies are inherent part of the current EHR documentation process commonly found in hospitals, not unique to the care facility under study.

CONCLUSION

We demonstrated pump event logs and EHR data can be utilized to study time discrepancies in infusion administration at scale. Such discrepancy should be further investigated at different hospitals to address the prevalence of the problem and improvement effort.

Implementation of a Mobile Application in Acute Stroke Care Documentation

Acute stroke care is a time-critical process. Improving communication and documentation process may support a positive effect on medical outcome. To achieve this goal, a new system using a mobile application has been integrated into existing infrastructure at Hannover Medical School (MHH). Within a pilot project, this system has been brought into clinical daily routine in February 2022. Insights generated may support further applications in clinical use-cases.

Integrating a New Dietetic Care Process in a Health Information System: A System and Process Analysis and Assessment

Managing routinely collected data in health care and public health is important for evaluation of interventions and answering research questions using “real life” and ”big data”. In addition to the technical requirements of information systems, both standardized terminology and standardized processes are needed. The aim of this project was to analyse and assess the integration of standardized terminology and document templates for a dietetic care process (DCP) into the health information system (HIS) in a hospital in Austria. Using an action research approach, the DCP was analysed through four expert interviews and the integration into the HIS through two expert interviews with observations. Key strengths and weaknesses for the main criteria (“integration of the ICF catalogue”, “adaption of the document templates”, “adaption of the DCP”, and the “adaption of the user authorizations”) were presented and proposals for improvement given. The system and process integration of the DCP is possible, and the document templates can be adapted with the software currently in use. Although an increase in resources and finances required is to be expected initially, the integration of a standardized dietetic terminology in combination with a standardized process is likely to improve the quality of care and support outcomes management and research.

Developing an Ontology for Documenting Adverse Events While Avoiding Pitfalls

Ontologies promise more benefits than terminologies in terms of data annotation and computer-assisted reasoning, by defining a hierarchy of terms and their relations within a domain. Here, we present central insights related to the development of an ontology for documenting events during interoperative neuromonitoring (IOM), for which we used the Basic Formal Ontology (BFO) as an upper-level ontology. This work has the following two goals: to describe the development of the IOM ontology and to guide the practice with respect to documenting of biomedical events, as available ontologies pose difficulties on certain issues. We address the following issues: (i) differentiate between the sets documentation, identification, continuant and explanation, understanding, occurrent as we had problems in applying the available ontology of adverse events, (ii) covering diseases and injuries in a consistent way, and (iii) deciding on which level to define relations.

The Medical Device Unique Device Identifier as the Single Source of Truth in Healthcare Enterprises - Roadmap for Implementation of the Clinically Integrated Supply Chain

Documentation and tracking of supplies, equipment and medical devices is central to operational, financial, and clinical aspects of safe, efficient, and effective patient care. The labeling of medical devices with a unique device identifier (UDI) creates the opportunity to tightly integrate device information across health information systems by using the UDI as the index "source of truth". Across 3 hospitals of the Duke University Health System, we executed a comprehensive implementation of UDI-based device and supply information management in our cardiac catheterization and electrophysiology laboratories. Following are our key insights. Implementing a UDI-centric environment is a complex undertaking requiring integration of information systems, management processes, and clinical workflows involving leadership, inventory management, supply chain, clinical and billing teams. Implementation involves the domains of procedure documentation, electronic health records (EHRs), charge capture and billing, and interface and information technology systems, including information systems vendors. Replacing manual processes with electronic messages is not simply an exercise in programming information systems - successful execution requires orchestrated re-engineering of clinical and operational workflows. Our initiative resulted in a more efficient and effective supply chain, eliminated operational and clinical documentation errors, automated the posting of device implant data to the EHR, reduced clinician burden, improved charge capture, and produced a substantial financial benefit, with return on investment recognized in well under 1 year. We believe our stepwise approach to accomplishing a clinically integrated supply chain can serve as a roadmap for other healthcare enterprises to follow.

Real-World Evidence of COVID-19 Patients' Data Quality in the Electronic Health Records

Despite the importance of electronic health records data, less attention has been given to data quality. This study aimed to evaluate the quality of COVID-19 patients' records and their readiness for secondary use. We conducted a retrospective chart review study of all COVID-19 inpatients in an academic healthcare hospital for the year 2020, which were identified using ICD-10 codes and case definition guidelines. COVID-19 signs and symptoms were higher in unstructured clinical notes than in structured coded data. COVID-19 cases were categorized as 218 (66.46%) "confirmed cases", 10 (3.05%) "probable cases", 9 (2.74%) "suspected cases", and 91 (27.74%) "no sufficient evidence". The identification of "probable cases" and "suspected cases" was more challenging than "confirmed cases" where laboratory confirmation was sufficient. The accuracy of the COVID-19 case identification was higher in laboratory tests than in ICD-10 codes. When validating using laboratory results, we found that ICD-10 codes were inaccurately assigned to 238 (72.56%) patients' records. "No sufficient evidence" records might indicate inaccurate and incomplete EHR data. Data quality evaluation should be incorporated to ensure patient safety and data readiness for secondary use research and predictive analytics. We encourage educational and training efforts to motivate healthcare providers regarding the importance of accurate documentation at the point-of-care.

Frequent but fragmented: use of note templates to document outpatient visits at an academic health center

Recent changes to billing policy have reduced documentation requirements for outpatient notes, providing an opportunity to rethink documentation workflows. While many providers use templates to write notes-whether to insert short phrases or draft entire notes-we know surprisingly little about how these templates are used in practice. In this retrospective cross-sectional study, we observed the templates that primary providers and other members of the care team used to write the provider progress note for 2.5 million outpatient visits across 52 specialties at an academic health center between 2018 and 2020. Templates were used to document 89% of visits, with a median of 2 used per visit. Only 17% of the 100 230 unique templates were ever used by more than one person and most providers had their own full-note templates. These findings suggest template use is frequent but fragmented, complicating template revision and maintenance. Reframing template use as a form of computer programming suggests ways to maintain the benefits of personalization while leveraging standardization to reduce documentation burden.

Face validity of standardized assessments for wheeled mobility & seating evaluations

A problem in the Complex Rehabilitation Technology industry is the lack of standardization in the assessment for wheeled mobility and seating (WMS). The aim of this paper was to identify assessment tools commonly used by clinicians during WMS evaluations. After the tools were identified by a panel of 12 subject matter experts, a presentation at the 2018 International Seating Symposium in Vancouver, Canada and the 2018 European Seating Symposium in Dublin, Ireland polled attendees via the Sli.do polling application to determine professional opinions of each tool, resulting in face validity for use in wheelchair evaluations. The Lawshe Content Validity Ratio was used to convert this anecdotal data into numerical data, indicating which tools were most and least used by attendees. Finally, a literature search was conducted to determine the reliability, validity, and International Classification of Functioning, Disability, & Health domain for each measure. The findings indicate that while there are many standardized and reliable assessment tools available for wheeled mobility and seating evaluations, most clinicians use only a few standardized assessment tools during WMS evaluations.

Genetic counseling clinical documentation: Practice Resource of the National Society of Genetic Counselors

Clinical documentation is an important extension of a genetic counseling encounter. The traditional types of clinical documentation include the clinical visit note (including follow-up visit note), letter to the referring physician, letter to the patient, and result summary to the patient and referring physician. Increasing patient volumes, new genetic counseling service delivery models, transition to electronic medical records (EMR), new specialty clinics in genetics, and advances in genetic testing technologies challenge the practice of writing multiple types of clinical documents. This practice resource (PR) seeks to provide best practices for U.S.-based genetic counselors to write efficient and comprehensive clinical documentation using a hybrid clinical document designed to facilitate communication between individual providers, providers, and patients/families, and providers and payers. The content of the hybrid clinical documentation will vary by genetic specialty but may include a summary of genetic services evaluation, genetic testing options and eligibility information, genetic test results, potential risks for genetic conditions, implications for family members, and medical management recommendations. An outline of a general hybrid document along with examples of hybrid clinic notes for three types of genetic counseling specialties is included in this document.

Formal representation of patients' care context data: the path to improving the electronic health record

Objective

To develop a collection of concept-relationship-concept tuples to formally represent patients’ care context data to inform electronic health record (EHR) development.

Materials and Methods

We reviewed semantic relationships reported in the literature and developed a manual annotation schema. We used the initial schema to annotate sentences extracted from narrative note sections of cardiology, urology, and ear, nose, and throat (ENT) notes. We audio recorded ENT visits and annotated their parsed transcripts. We combined the results of each annotation into a consolidated set of concept-relationship-concept tuples. We then compared the tuples used within and across the multiple data sources.

Results

We annotated a total of 626 sentences. Starting with 8 relationships from the literature, we annotated 182 sentences from 8 inpatient consult notes (initial set of tuples = 43). Next, we annotated 232 sentences from 10 outpatient visit notes (enhanced set of tuples = 75). Then, we annotated 212 sentences from transcripts of 5 outpatient visits (final set of tuples = 82). The tuples from the visit transcripts covered 103 (74%) concepts documented in the notes of their respective visits. There were 20 (24%) tuples used across all data sources, 10 (12%) used only in inpatient notes, 15 (18%) used only in visit notes, and 7 (9%) used only in the visit transcripts.

Conclusions

We produced a robust set of 82 tuples useful to represent patients’ care context data. We propose several applications of our tuples to improve EHR navigation, data entry, learning health systems, and decision support.

Is nursing and midwifery clinical documentation a burden? An empirical study of perception versus reality

AIMS AND OBJECTIVES

To measure time spent on clinical documentation and nurses and midwives' perceptions of this aspect of their role.

BACKGROUND

Nurses and midwives rely on accurate documentation when planning care. However, documenting and communicating care can be onerous, time-consuming and at times duplicated or redundant. While documentation provides a record and means of communicating care, it should not detract from the delivery of care.

DESIGN

An observational time and motion study and survey design reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

METHODS

The study was conducted with Western Australian nurses and midwives working in a private not-for-profit hospital from July-October 2019. An observational study was undertaken to measure the practice of documentation on each shift. Participants' perceptions of clinical documentation were measured using a self-report survey.

RESULTS

A total of 120 hr of observation were undertaken. Total observed time spent on documentation was 28.1% on morning shifts, 22.7% on afternoon shifts and 20.9% on night duty. The mean self-reported time for clinical documentation was 50.4% on morning shifts, 40.7% on afternoon shifts and 37.9% on night duty. Issues with duplication and unnecessary paperwork were identified.

CONCLUSIONS

Although participants tended to overestimate time spent on documentation, it still consumed a significant proportion of time. Frustrations with paperwork may amplify nurses' negative perceptions of documentation. Clinical documentation needs to be reviewed, revised and reduced to release time back to direct patient care and reduce clinician dissatisfaction.

RELEVANCE TO CLINICAL PRACTICE

Clinical documentation is required in all areas of clinical practice and forms an important legal record. Understanding the demands of clinical documentation can assist in reviewing and improving documentation to release time back to direct patient care.

Effectiveness of an Electronic Communication Tool on Transitions in Care From the Intensive Care Unit: Protocol for a Cluster-Specific Pre-Post Trial

BACKGROUND

Transitions in care are vulnerable periods in health care that can expose patients to preventable errors due to incomplete or delayed communication between health care providers. Transitioning critically ill patients from intensive care units (ICUs) to other patient care units (PCUs) is particularly risky, due to the high acuity of the patients and the diversity of health care providers involved in their care. Instituting structured documentation to standardize written communication between health care providers during transitions has been identified as a promising means to reduce communication breakdowns. We developed an evidence-informed, computer-enabled, ICU-specific structured tool-an electronic transfer (e-transfer) tool-to facilitate and standardize the composition of written transfer summaries in the ICUs of one Canadian city. The tool consisted of 10 primary sections with a user interface combination of structured, automated, and free-text fields.

OBJECTIVE

Our overarching goal is to evaluate whether implementation of our e-transfer tool will improve the completeness and timeliness of transfer summaries and streamline communications between health care providers during high-risk transitions.

METHODS

This study is a cluster-specific pre-post trial, with randomized and staggered implementation of the e-transfer tool in four hospitals in Calgary, Alberta. Hospitals (ie, clusters) were allocated randomly to cross over every 2 months from control (ie, dictation only) to intervention (ie, e-transfer tool). Implementation at each site was facilitated with user education, point-of-care support, and audit and feedback. We will compare transfer summaries randomly sampled over 6 months postimplementation to summaries randomly sampled over 6 months preimplementation. The primary outcome will be a binary composite measure of the timeliness and completeness of transfer summaries. Secondary measures will include overall completeness, timeliness, and provider ratings of transfer summaries; hospital and ICU lengths of stay; and post-ICU patient outcomes, including ICU readmission, adverse events, cardiac arrest, rapid response team activation, and mortality. We will use descriptive statistics (ie, medians and means) to describe demographic characteristics. The primary outcome will be compared within each hospital pre- and postimplementation using separate logistic regression models for each hospital, with adjustment for patient characteristics.

RESULTS

Participating hospitals were cluster randomized to the intervention between July 2018 and January 2019. Preliminary extraction of ICU patient admission lists was completed in September 2019. We anticipate that evaluation data collection will be completed by early 2021, with first results ready for publication in spring or summer 2021.

CONCLUSIONS

This study will report the impact of implementing an evidence-informed, computer-enabled, ICU-specific structured transfer tool on communication and preventable medical errors among patients transferred from the ICU to other hospital care units.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03590002; https://www.clinicaltrials.gov/ct2/show/NCT03590002.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18675.

Patient Care Documentation in the Secondary School Setting: Unique Challenges and Needs

CONTEXT

Athletic trainers (ATs) recognize patient care documentation as an important part of clinical practice. However, ATs using 1 electronic medical record (EMR) platform reported low accountability and lack of time as barriers to documentation. Whether ATs using paper, other EMRs, or a combined paper-electronic system exhibit similar behaviors or experience similar challenges is unclear.

OBJECTIVE

To explore ATs' documentation behaviors and perceived challenges while using various systems to document patient care in the secondary school setting.

DESIGN

Qualitative study.

SETTING

Individual telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

Twenty ATs (12 women, 8 men; age = 38 ± 14 years; clinical experience = 15 ± 13 years; from National Athletic Trainers' Association Districts 2, 3, 6, 7, 8, 9, and 10) were recruited via purposeful and snowball-sampling techniques.

DATA COLLECTION AND ANALYSIS

Two investigators conducted semistructured interviews, which were audio recorded and transcribed verbatim. Following the consensual qualitative research tradition, 3 researchers independently coded transcripts in 4 rounds using a codebook to confirm codes, themes, and data saturation. Multiple researchers, member checking, and peer reviewing were the methods used to triangulate data and enhance trustworthiness.

RESULTS

The secondary school setting was central to 3 themes. The ATs identified challenges to documentation, including lack of time due to high patient volume and multiple providers or locations where care was provided. Oftentimes, these challenges affected their documentation behaviors, including the process of and criteria for whether to document or not, content documented, and location and timing of documentation. To enhance patient care documentation, ATs described the need for more professional development, including resources or specific guidelines and viewing how documentation has been used to improve clinical practice.

CONCLUSIONS

Challenges particular to the secondary school setting affected ATs' documentation behaviors, regardless of the system used to document care. Targeted professional development is needed to promote best practices in patient care documentation.

Sharing clinical notes, and placebo and nocebo effects: Can documentation affect patient health?

This paper connects findings from the field of placebo studies with research into patients' interactions with their clinician's visit notes, housed in their electronic health records. We propose specific hypotheses about how features of clinicians' written notes might trigger mechanisms of placebo and nocebo effects to elicit positive or adverse health effects among patients. Bridging placebo studies with (a) survey data assaying patient and clinician experiences with portals and (b) randomized controlled trials provides preliminary support for our hypotheses. We conclude with actionable proposals for testing our understanding of the health effects of access to visit notes.

Inter-rater Reliability of a Clinical Documentation Rubric Within Pharmacotherapy Problem-Based Learning Courses

Objective. To evaluate a clinical documentation rubric for pharmacotherapy problem-based learning (PBL) courses using inter-rater reliability (IRR) among different evaluators. Methods. A rubric was adapted for use in grading student pharmacists' clinical documentation in pharmacotherapy PBL courses. Multiple faculty evaluators used the rubric to assess student pharmacists' clinical documentation. The mean rubric score given by the evaluators and the standard deviation were calculated. Intra-class correlation coefficients (ICC) were calculated to determine the inter-rater reliability (IRR) of the rubric. Results. Three hundred seventeen clinical documentation submissions were scored twice by multiple evaluators using the rubric. The mean initial evaluation score was 9.1 (SD=0.9) and the mean second evaluation score was 9.1 (SD=0.9), with no significant difference found between the two. The overall ICC was 0.7 across multiple graders, indicating good IRR. Conclusion. The clinical documentation rubric demonstrated overall good IRR between multiple evaluators when used in pharmacotherapy PBL courses. The rubric will undergo additional evaluation and continuous quality improvement to ensure that student pharmacists are provided with the formative feedback they need.

Machine learning mortality classification in clinical documentation with increased accuracy in visual-based analyses

AIM

The role of machine learning on clinical documentation for predictive outcomes remains undefined. We aimed to compare three neural networks on inpatient providers' notes to predict mortality in neonatal hypoxic-ischaemic encephalopathy (HIE).

METHODS

Using Children's Hospitals Neonatal Database, non-anomalous neonates with HIE treated with therapeutic hypothermia were identified at a single-centre. Data were linked with the initial seven days of documentation. Exposures were derived using the databases and applying convolutional and two recurrent neural networks. The primary outcome was mortality. The predictive accuracy and performance measures for models were determined.

RESULTS

The cohort included 52 eligible infants. Most infants survived (n = 36, 69%) and 23 had severe HIE (44%). Neural networks performed above baseline and differed in their median accuracy for predicting mortality (P = .0001): recurrent models with long short-term memory 69% (25^th , 75^th percentile 65, 73%) and gated-recurrent model units 65% (62, 69%) and convolutional 72% (64, 96%). Convolutional networks' median specificity was 81% (72, 97%).

CONCLUSION

The neural network models demonstrated fundamental validity in predicting mortality using inpatient provider documentation. Convolutional models had high specificity for (excluding) mortality in neonatal HIE. These findings provide a platform for future model training and ultimately tool development to assist clinicians in patient assessments and risk stratifications.

A resident-led project to improve documentation of overweight and obesity in a primary care clinic

Background: Although the prevalence of overweight and obesity (OW/OB) has increased in the last three decades, studies show that these conditions are sub-optimally documented by physicians. Health information technology tools have varying effects on improving documentation of OW/OB but often have to be complemented with other interventions to be effective.

Objective: Upon identifying low rates of documentation of diagnoses of overweight and obesity by resident and attending physicians, despite the use of an electronic health record (EHR) with automated BMI calculations, we performed a quality improvement (QI) project to improve documentation of these diagnoses for patients in our community hospital primary care clinic.

Methods: The EHR was reviewed to determine documentation rates by resident and attending physicians between 1 March 2018 and 31 September 2018. We collected pre-intervention data, developed interventions, and implemented tests of change using Plan-Do-Study-Act (PDSA) cycles to improve documentation of OW/OB.

Results: Documentation of overweight and obesity diagnoses increased from a baseline of 46% to 79% over a 20-week period after initiation of our project.

Conclusion: We demonstrate the successful implementation of resident-led, multi-faceted interventions in a team-based QI project to optimize documentation of OW/OB in the EHR.

Predicting survival in cancer patients with and without 30-day readmission of an unplanned hospitalization using a deficit accumulation approach

BACKGROUND

For cancer patients with an unplanned hospitalization, estimating survival has been limited. We examined factors predicting survival and investigated the concept of using a deficit-accumulation survival index (DASI) in this population.

METHODS

Data were abstracted from medical records of 145 patients who had an unplanned 30-day readmission between 01/01/16 and 09/30/16. Comparison data were obtained for patients who were admitted as close in time to the date of index admission of a study patient, but who did not experience a readmission within 30 days of their discharge date. Our survival analysis compared those readmitted within 30 days versus those who were not. Scores from 23 medical record elements used in our DASI system categorized patients into low-, moderate-, and high-score groups.

RESULTS

Thirty-day readmission was strongly associated with the survival (adjusted hazard ratio [HR] 2.39; 95% confidence interval [CI], 1.46-3.92). Patients readmitted within 30 days of discharge from index admission had a median survival of 147 days (95% CI, 85-207) versus patients not readmitted who had not reached median survival by the end of the study (P < .0001). DASI was useful in predicting the survival; median survival time was 78 days (95% CI, 61-131) for the high score, 318 days (95% CI, 207-426) for the moderate score, and not reached as of 426 days (95% CI, 251 to undetermined) for the low-score DASI group (P < .0001).

CONCLUSIONS

Patients readmitted within 30 days of an unplanned hospitalization are at higher risk of mortality than those not readmitted. A novel DASI developed from clinical documentation may help to predict survival in this population.

Speech recognition for clinical documentation from 1990 to 2018: a systematic review

OBJECTIVE

The study sought to review recent literature regarding use of speech recognition (SR) technology for clinical documentation and to understand the impact of SR on document accuracy, provider efficiency, institutional cost, and more.

MATERIALS AND METHODS

We searched 10 scientific and medical literature databases to find articles about clinician use of SR for documentation published between January 1, 1990, and October 15, 2018. We annotated included articles with their research topic(s), medical domain(s), and SR system(s) evaluated and analyzed the results.

RESULTS

One hundred twenty-two articles were included. Forty-eight (39.3%) involved the radiology department exclusively and 10 (8.2%) involved emergency medicine; 10 (8.2%) mentioned multiple departments. Forty-eight (39.3%) articles studied productivity; 20 (16.4%) studied the effect of SR on documentation time, with mixed findings. Decreased turnaround time was reported in all 19 (15.6%) studies in which it was evaluated. Twenty-nine (23.8%) studies conducted error analyses, though various evaluation metrics were used. Reported percentage of documents with errors ranged from 4.8% to 71%; reported word error rates ranged from 7.4% to 38.7%. Seven (5.7%) studies assessed documentation-associated costs; 5 reported decreases and 2 reported increases. Many studies (44.3%) used products by Nuance Communications. Other vendors included IBM (9.0%) and Philips (6.6%); 7 (5.7%) used self-developed systems.

CONCLUSION

Despite widespread use of SR for clinical documentation, research on this topic remains largely heterogeneous, often using different evaluation metrics with mixed findings. Further, that SR-assisted documentation has become increasingly common in clinical settings beyond radiology warrants further investigation of its use and effectiveness in these settings.

Impact of Daily Electronic Laboratory Alerting on Early Detection and Clinical Documentation of Acute Kidney Injury in Hospital Settings

Acute kidney injury, especially early-stage disease, is a common hospital comorbidity requiring timely recognition and treatment. We investigated the effect of daily laboratory alerting of patients at risk for acute kidney injury as measured by documented International Classification of Diseases diagnoses. A quasi-experimental study was conducted at 8 New York hospitals between January 1, 2014, and June 30, 2017. Education of clinical documentation improvement specialists, physicians, and nurses was conducted from July 1, 2014, to December 31, 2014, prior to initiating daily hospital-wide laboratory acute kidney injury alerting on January 1, 2015. Incidence based on documented International Classification of Diseases diagnosis of acute kidney injury and acute tubular necrosis during the intervention periods (3 periods of 6 months each: January 1 to June 30 of 2015, 2016, and 2017) were compared to one preintervention period (January 1, 2014, to June 30, 2014). The sample consisted of 269 607 adult hospital discharges, among which there were 39 071 episodes based on laboratory estimates and 27 660 episodes of documented International Classification of Diseases diagnoses of acute kidney injury or acute tubular necrosis. Documented incidence improved significantly from the 2014 preintervention period (5.70%; 95% confidence interval: 5.52%-5.88%) to intervention periods in 2015 (9.89%; 95% confidence interval, 9.66%-10.12%; risk ratio = 1.73, P < .001), 2016 (12.76%; 95% confidence interval, 12.51%-13.01%; risk ratio = 2.24, P < .001), and 2017 (12.49%; 95% confidence interval, 12.24%-12.74%; risk ratio = 2.19, P < .001). A multifactorial intervention comprising daily laboratory alerting and education of physicians, nurses, and clinical documentation improvement specialists led to increased recognition and clinical documentation of acute kidney injury.

The Potential Impact of Scribes on Medical School Applicants and Medical Students with the New Clinical Documentation Guidelines

The presence of scribes in various specialties, including internal medicine, is being heralded as a way to decrease clinician documentation time and burnout. Many medical school applicants become scribes to understand life as a doctor and gain clinical experience. Scribing is already perceived by some as a new key to successfully gaining entrance to medical school. One season of our admissions data showed that scribes were more likely to be admitted (OR = 1.61). Scribes may also inadvertently make it harder for medical schools to secure clinical placements for medical students. While trained scribes are highly valued by providers struggling to deal with increasing documentation burdens, supervising or training scribes also requires time that cannot be devoted to teaching. Medical documentation duties could provide valuable learning experiences for medical students. The recent ruling allowing medical students to contribute directly to clinical documentation without requiring redocumentation by supervisors gives medical schools and clinician-educators an opportunity to consider the unintended consequences of the scribe movement for medical education. Educators should consider when and how students can maximize the educational benefits of participating in patient documentation despite the templated methods commonly used in electronic health record (EHR) systems.

National Survey of Pediatric Care Providers: Assessing Time and Impact of Coding and Documentation in Physician Practice

BACKGROUND

Documentation and billing/coding are essential to medical practice. Physicians spend significant time documenting to meet coding and medicolegal requirements, potentially reducing time for patient care and learning. We sought to assess time spent charting in pediatric practice and provider understanding and comfort level regarding billing/coding.

METHODS

An anonymous web-based survey was emailed to members of American Academy of Pediatrics Section of Pediatric Trainees practicing in the United States.

RESULTS

A total of 601 trainees responded to the survey. Thirty-seven percent of trainees spent more than half of patient encounter time documenting in outpatient settings while 62% ( P < .01) in inpatient settings. There was a positive correlation between trainees' apprehension about documentation and reporting increased stress due to documentation ( r = 0.32, P < 0.001). Sixty-two percent respondents had no prior training of billing/coding, and >70% feel necessity of including billing/coding in the medical curriculum ( P < 0.0001).

CONCLUSIONS

Our study highlights increasing burden of documentation in practice. Majority of pediatric trainees feel the need to including billing/coding skills as a part of medical curriculum.

A quality improvement intervention to enhance performance and perceived confidence of new internal medicine residents

Background: Orientation for new medical residents is challenging due to the diversity of prior experiences and cultural backgrounds and is compounded by a lack of orientation curricula that adequately addresses the needs of the medical residents to allow them to perform their duties in an efficient manner from the start. The beginning of residency training is associated with reduced quality of healthcare widely referred to as the ‘July effect’.

Objective: To assess the impact of a peer-led orientation for new interns on (a) self-reported confidence level, (b) improvement in performance of first-year residents in appropriate clinical documentation and efficient discharge procedures and protocols.

Design/methods: In June 2016, a hybrid of interactive teaching and simulation exercises was used to teach documentation of critical information, such as discharge medication reconciliation and discharge summary. A handout of an intern guide/manual was also provided. The previous year’s data served as comparison/control data. Comparison data were obtained for both groups from hospital’s utilisation review department.

Results: Twenty-one of 23 expected new interns (91%) participated in the intervention. There was a significant decrease in non-compliance for clinical documentation in the intervention group compared to the control group. The self-reported confidence level in the intervention group increased 34%.

Conclusions: Such peer-to-peer orientation has the potential to effectively improve appropriate documentation and discharge process by new residents and may help to reduce the ‘July effect’.

Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration

BACKGROUND

Copy and paste functionality can support efficiency during clinical documentation, but may promote inaccurate documentation with risks for patient safety. The Partnership for Health IT Patient Safety was formed to gather data, conduct analysis, educate, and disseminate safe practices for safer care using health information technology (IT).

OBJECTIVE

To characterize copy and paste events in clinical care, identify safety risks, describe existing evidence, and develop implementable practice recommendations for safe reuse of information via copy and paste.

METHODS

The Partnership 1) reviewed 12 reported safety events, 2) solicited expert input, and 3) performed a systematic literature review (2010 to January 2015) to identify publications addressing frequency, perceptions/attitudes, patient safety risks, existing guidance, and potential interventions and mitigation practices.

RESULTS

The literature review identified 51 publications that were included. Overall, 66% to 90% of clinicians routinely use copy and paste. One study of diagnostic errors found that copy and paste led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care. Copy and paste can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart. Existing guidance identified specific responsibilities for authors, organizations, and electronic health record (EHR) developers. Analysis of 12 reported copy and paste safety events was congruent with problems identified from the literature review.

CONCLUSION

Despite regular copy and paste use, evidence regarding direct risk to patient safety remains sparse, with significant study limitations. Drawing on existing evidence, the Partnership developed four safe practice recommendations: 1) Provide a mechanism to make copy and paste material easily identifiable; 2) Ensure the provenance of copy and paste material is readily available; 3) Ensure adequate staff training and education; 4) Ensure copy and paste practices are regularly monitored, measured, and assessed.

Developing Validity Evidence for the Written Pediatric History and Physical Exam Evaluation Rubric

OBJECTIVE

The written history and physical examination (H&P) is an underutilized source of medical trainee assessment. The authors describe development and validity evidence for the Pediatric History and Physical Exam Evaluation (P-HAPEE) rubric: a novel tool for evaluating written H&Ps.

METHODS

Using an iterative process, the authors drafted, revised, and implemented the 10-item rubric at 3 academic institutions in 2014. Eighteen attending physicians and 5 senior residents each scored 10 third-year medical student H&Ps. Inter-rater reliability (IRR) was determined using intraclass correlation coefficients. Cronbach α was used to report consistency and Spearman rank-order correlations to determine relationships between rubric items. Raters provided a global assessment, recorded time to review and score each H&P, and completed a rubric utility survey.

RESULTS

Overall intraclass correlation was 0.85, indicating adequate IRR. Global assessment IRR was 0.89. IRR for low- and high-quality H&Ps was significantly greater than for medium-quality ones but did not differ on the basis of rater category (attending physician vs. senior resident), note format (electronic health record vs nonelectronic), or student diagnostic accuracy. Cronbach α was 0.93. The highest correlation between an individual item and total score was for assessments was 0.84; the highest interitem correlation was between assessment and differential diagnosis (0.78). Mean time to review and score an H&P was 16.3 minutes; residents took significantly longer than attending physicians. All raters described rubric utility as "good" or "very good" and endorsed continued use.

CONCLUSIONS

The P-HAPEE rubric offers a novel, practical, reliable, and valid method for supervising physicians to assess pediatric written H&Ps.

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.

Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record

BACKGROUND

Communication errors are identified as a root cause contributing to a majority of sentinel events. The clinical note is a cornerstone of physician communication, yet there are few published interventions on teaching note writing in the electronic health record (EHR). This is a prospective, two-site, quality improvement project to assess and improve the quality of clinical documentation in the EHR using a validated assessment tool.

METHODS

Internal Medicine (IM) residents at the University of Kentucky College of Medicine (UK) and Montefiore Medical Center/Albert Einstein College of Medicine (MMC) received one of two interventions during an inpatient ward month: either a lecture, or a lecture and individual feedback on progress notes. A third group of residents in each program served as control. Notes were evaluated with the Physician Documentation Quality Instrument 9 (PDQI-9).

RESULTS

Due to a significant difference in baseline PDQI-9 scores at MMC, the sites were not combined. Of 75 residents at the UK site, 22 were eligible, 20 (91%) enrolled, 76 notes in total were scored. Of 156 residents at MMC, 22 were eligible, 18 (82%) enrolled, 40 notes in total were scored. Note quality did not improve as measured by the PDQI-9.

CONCLUSION

This educational quality improvement project did not improve the quality of clinical documentation as measured by the PDQI-9. This project underscores the difficulty in improving note quality. Further efforts should explore more effective educational tools to improve the quality of clinical documentation in the EHR.

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 Impact of Documentation Training on Performance Reporting

With the advent of public reporting of clinical performance for physicians, the need for accurate documentation is essential. This study tested the hypothesis that a short tutorial on five key documentation tips for a group of colorectal surgeons could significantly improve their reported clinical performance. Data was collected on a total of 626 consecutive inpatients before and after the introduction of a short tutorial focusing on five key documentation tips to a group of colorectal surgeons. Quality metrics were compared between the two time periods. Significant improvements were observed for complications (p = 0.001), morbidity (p = 0.046), ileus (p = 0.027), and digestive system complications (p < 0.01). There was no difference in mortality (p = 0.569) or readmissions (p = 0.920). A short tutorial focusing on five key documentation tips is associated with improvement in the reported clinical performance of colorectal surgeons.

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

BACKGROUND

There are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders.

METHODS

Using purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding.

RESULTS

The 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content.

CONCLUSIONS

Perspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.

A pharmacotherapy capstone course to advance pharmacy students' clinical documentation skills

OBJECTIVE

To implement and assess the effectiveness of a capstone pharmacotherapy course designed to integrate in-class curriculum using patient cases and drug-information questions. The course was intended to improve third-year doctor of pharmacy (PharmD) students' clinical documentation skills in preparation for beginning advanced pharmacy practice experiences (APPEs).

DESIGN

This 2-credit, semester-long course consisted of 6 patient cases and 12 drug-information questions posted electronically on an Internet-based medical chart, a public health presentation, a knowledge examination, and an objective standardized performance assessment. In class, students engaged in active-learning exercises and clinical problem-solving. Students worked outside of class in small groups to retrieve and discuss assigned articles and review medication information in preparation for in-class discussions.

ASSESSMENT

A rubric was used to assess the patient cases and questions that students completed and submitted individually. Data for 4 consecutive course offerings (n=622) were then analyzed. A significant improvement was found in the "misplaced" but not the "missing" documentation ratings for both assessment and plan notes in the final assessment compared with baseline. In course evaluations, the majority of students agreed that the course integrated material across the curriculum (97%) and improved their clinical writing skills (80.5%).

CONCLUSION

A capstone pharmacy course was successful in integrating and reviewing much of the material covered across the PharmD curriculum and in improving students' clinical documentation skills.

Lessons learned from an ICD-10-CM clinical documentation pilot study

On October 1, 2013, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) will be mandated for use in the United States in place of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). This new classification system will used throughout the nation's healthcare system for recording diagnoses or the reasons for treatment or care. A pilot study was conducted to determine whether current levels of inpatient clinical documentation provide the detail necessary to fully utilize the ICD-10-CM classification system for heart disease, pneumonia, and diabetes cases. The design of this pilot study was cross-sectional. Four hundred ninety-one de-identified records from two sources were coded using ICD-10-CM guidelines and codebooks. The findings of this study indicate that healthcare organizations need to assess clinical documentation and identify gaps. In addition, coder proficiency should be assessed prior to ICD-10-CM implementation to determine the need for further education and training in the biomedical sciences, along with training in the new classification system.

Physician-Driven Management of Patient Progress Notes in an Intensive Care Unit

We describe fieldwork in which we studied hospital ICU physicians and their strategies and documentation aids for composing patient progress notes. We then present a clinical documentation prototype, activeNotes, that supports the creation of these notes, using techniques designed based on our fieldwork. ActiveNotes integrates automated, context-sensitive patient data retrieval, and user control of automated data updates and alerts via tagging, into the documentation process. We performed a qualitative study of activeNotes with 15 physicians at the hospital to explore the utility of our information retrieval and tagging techniques. The physicians indicated their desire to use tags for a number of purposes, some of them extensions to what we intended, and others new to us and unexplored in other systems of which we are aware. We discuss the physicians' responses to our prototype and distill several of their proposed uses of tags: to assist in note content management, communication with other clinicians, and care delivery.