Improving trainee clinical documentation through a novel curriculum in internal medicine.

Autor: Weber DE; Department of Internal Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA., Held JD; Department of Internal Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA., Jandarov RA; Department of Internal Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA., Kelleher M; Department of Internal Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA., Kinnear B; Department of Internal Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA., Sall DR; Department of Internal Medicine, HonorHealth Thompson Peak Medical Center, University of Arizona College of Medicine-Phoenix, Scottsdale, Arizona, USA., O'Toole JK; Department of Internal Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
Jazyk: angličtina
Zdroj: Journal of hospital medicine [J Hosp Med] 2022 Jan; Vol. 17 (1), pp. 28-35.
DOI: 10.1002/jhm.27410
Abstrakt: Background: Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown.
Objective: The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality.
Designs: Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention.
Settings and Participants: Admission notes written by University of Cincinnati interns were assessed.
Interventions: The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback.
Main Outcomes and Measures: Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT).
Results: Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (β = .08, p = .03 and β = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time.
Conclusion: Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.
(© 2022 Society of Hospital Medicine.)
Databáze: MEDLINE
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