Documentation quality of patient-directed discharge and early warning interactions in an adult inpatient service

Documentation quality of patient-physician discussion, assessment, and intervention at the time of patient-directed discharges (elopement and 'against medical advice' discharges) is found to be poor in available studies and, importantly, may be a proxy for quality of care delivered. Less is known about the patient-physician interactions and documentation at the time a patient vocalizes the desire to leave early ('early warning interaction') prior to a patient-directed discharge. This was a cohort study comprising a retrospective chart review of patients leaving 'against medical advice' from an inpatient internal medicine-infectious disease service at a tertiary medical center from 01 July 2020 to 24 September 2021. Documentation quality was assessed using 11 extractable factors detailing patient-physician conversation elements from the assess, investigate, mitigate, explain, and document framework, plus related interventions pertinent to patient safety and care optimization. Descriptive statistics were mainly utilized with inferential statistics and regression models as appropriate. Fifty-two patients left against medical advice and 49 eloped; 11% had an early warning interaction. Aggregate documentation quality scores at early warning interaction (13%), 'against medical advice' discharge (42%), and at elopement (31%) were low. Half of the suggested documentation elements were recorded in no patients. The overall documentation quality was poor, suggesting the need for further training and interventions to facilitate more thorough documentation.

Understanding how physician perceptions of job demand and process benefits evolve during CPOE implementation

We examine how physicians' perceptions of two computerized provider order entry (CPOE) capabilities, standardisation of care protocols and documentation quality, are associated with their perceptions of turnaround time, medical error, and job demand at three phases of CPOE implementation: pre-go-live, initial use, and continued use. Through a longitudinal study at a large urban hospital, we find standardisation of care protocols is positively associated with turnaround time reduction in all phases but positively associated with job demand increase only in the initial use phase. Standardisation also has a positive association with medical error reduction in the initial use phase, but later this effect becomes fully mediated through turnaround time reduction in the continued use phase. Documentation quality has a positive association with medical error reduction in the initial use phase and this association strengthens in the continued use phase. Our findings provide insights to effectively manage physicians' response to CPOE implementation.

[Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings]

Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings Abstract. Background: In Germany, there was previously no instrument for the systematic recording of preferences for the everyday living of older and people in need of care. Subsequently, in a pilot study, an instrument was translated in a culturally sensitive way (PELI-D), piloted and tested psychometrically. In terms of documentation quality, it is important that the preferences recorded by nursing staff are written down in the nursing record using PELI-D, plausibly based on the nursing process.

AIM

To find out which preferences, assessed by the nursing staff in the pilot study with the PELI-D, were written down in the nursing record.

METHODS

An exploratory document analysis was carried out. Included were 13 nursing records and five discussion participants from five institutions in three nursing settings. The data were evaluated descriptively and by a structuring content analysis.

RESULTS

A total of 2% of the preferences, which were assessed with the PELI-D, were found in the nursing records and may be due to the use of PELI-D. Preferences mainly from the categories "interventions" and "biography" were found in the nursing record.

CONCLUSIONS

98% of the preferences assessed with the PELI-D were not written down. This can probably be attributed to the fact that the PELI-D was an "innovation" for the nursing staff. Therefore, the execution of an implementation study seems to be reasonable to improve the plausibility of the captured PELI-D data in the nursing documentation. In the context of this, it is also recommended to analyze how the PELI-D influences nursing processes and contents of the nursing record.

Impact of Patient Load on the Quality of Electronic Medical Record Documentation

OBJECTIVE

American College of Graduate Medical Education (ACGME) recommends ongoing care of 10 patients per resident however its implication is unclear. We hypothesized EMR quality to vary based on patient load and call status.

METHODS

We conducted a double-blind, single-center, retrospective observational study between 2017 and 2019 to investigate the quality and accuracy of resident documentation using the Responsible Electronic Documentation (RED) Checklist, a validated scoring system.

RESULTS

A total of 234 independent charts were analyzed and 80 met scoring criteria. Average patients per residents was 4, 9.1, 7.2, and 5.5 on "call" day (D0), "post-call" day (D1), "mid-call" day (D2), and "pre-call" day (D3), respectively. Mean RED checklist scores were 68.1%, 57%, 68.6%, and 72.1% on the above call status. The difference in score between D3 and D1 was statistically significant (P = .00042). There was a negative correlation between score and number of patients per resident (r = -0.286, P = .010).

CONCLUSION

EMR documentation quality is directly impacted by patient load and resident call status with the lowest documentation quality on post-call day, correlating with patient load.

Relationship between documentation method and quality of chronic disease visit notes

OBJECTIVE

To assses the relationship between methods of documenting visit notes and note quality for primary care providers (PCPs) and specialists, and to determine the factors that contribute to higher quality notes for two chronic diseases.

METHODS

Retrospective chart review of visit notes at two academic medical centers. Two physicians rated the subjective quality of content areas of the note (vital signs, medications, lifestyle, labs, symptoms, assessment & plan), overall quality, and completed the 9 item Physician Documentation Quality Instrument (PDQI-9). We evaluated quality ratings in relation to the primary method of documentation (templates, free-form or dictation) for both PCPs and specialists. A one factor analysis of variance test was used to examine differences in mean quality scores among the methods.

RESULTS

A total of 112 physicians, 71 primary care physicians (PCP) and 41 specialists, wrote 240 notes. For specialists, templated notes had the highest overall quality scores (p≤0.001) while for PCPs, there was no statistically significant difference in overall quality score. For PCPs, free form received higher quality ratings on vital signs (p = 0.01), labs (p = 0.002), and lifestyle (p = 0.002) than other methods; templated notes had a higher rating on medications (p≤0.001). For specialists, templated notes received higher ratings on vital signs, labs, lifestyle and medications (p = 0.001).

DISCUSSION

There was no significant difference in subjective quality of visit notes written using free-form documentation, dictation or templates for PCPs. The subjective quality rating of templated notes was higher than that of dictated notes for specialists.

CONCLUSION

As there is wide variation in physician documentation methods, and no significant difference in note quality between methods, recommending one approach for all physicians may not deliver optimal results.