A few years ago, Kate Carlson, M.D., assistant professor of Pediatrics and assistant medical director of the Vanderbilt Pediatric Primary Care Clinic, noticed a high incidence of delayed documentation among the group of residents assigned to the clinic at Monroe Carell Jr. Children’s Hospital at Vanderbilt.
“The expectation within our clinic is that the notes from a visit should be completed within three days,” Carlson said. “We discovered that this was not happening and began tracking the rates of documentation completion over a period of time.
In an effort to improve both resident and attending compliance with documentation, Carlson created a two-year study project within the Primary Care Clinic, which is staffed by 74 residents and supervised by 17 attending physicians. The study’s findings were published recently in Academic Medicine.
At the beginning of the study, only 55 percent of documentation was completed within the expected time frame, said Carlson.
Lack of time is a common issue for all residents, Carlson said. But she recognized that documenting was a priority and changes needed to be made.
She used quality improvement methods to help improve rates of documentation, including educating the residents about the importance of getting the notes done in a timely manner as well as prompting attending physicians to follow up. The various interventions made no difference.
“We then created a template form specific to each age group for well-child checks,” said Carlson. “There were 19 different forms that incorporated the screening and guidance guidelines recommended by the American Academy of Pediatrics.
“When we introduced these forms, there was a rapid uptake of use. Compliance among residents increased to 79 percent,” said Carlson.
Attending physician submission rates also improved from 38 percent to 83 percent.
“Documentation completion is a common issue among physicians on all levels,” she said. “We wanted to make improvements in compliance while also taking into account the level of stress associated with documentation practices.”
Another interesting finding — residents’ satisfaction was high with this kind of documentation. Ratings increased from 21 percent to 86 percent and stress associated with documentation during this period decreased from 61 to 29 percent.
“It has been an interesting foray into ‘how do you change the culture to prioritize documentation as part of patient care?’
“We are continually trying to figure out how to decrease the burden of documentation while still providing decision support for well-child care.”
Most recently, Carlson’s team introduced accountability measures via a weekly review of notes, which brought the completion rates to 100 percent.
She said the next step in improving documentation is to teach patient-centered, computer-based recording in exam rooms.