An automated procedure logging system improves resident documentation compliance

Area of Science:

• Medical Education
• Health Informatics
• Emergency Medicine

Background:

• Accurate procedure logging is crucial for resident education and competency assessment in Emergency Medicine (EM).
• Manual logging methods are often incomplete and inaccurate, posing challenges for evaluating resident performance.
• Existing systems may not efficiently capture all procedures performed by residents.

Purpose of the Study:

• To evaluate the impact of an automated procedure logging (APL) system on the quantity of procedures logged by EM residents.
• To assess changes in the completeness and accuracy of procedure logging after APL implementation.
• To measure resident compliance with the new APL system.

Main Methods:

• A before-and-after study design was employed at a large urban academic medical center.
• An APL system was developed to extract procedure data from the electronic medical record (EMR).
• Mean daily procedure logs were compared pre- and post-APL implementation using a two-sample t-test; completeness and accuracy were assessed via random sampling and Fisher's exact test.

Main Results:

• The mean daily number of logged procedures increased by 168% post-APL (10.0 to 26.8, p < 0.001).
• APL-logged procedures demonstrated significantly higher completeness (76% vs. 100%, p < 0.001) and accuracy (87% vs. 99%, p < 0.001).
• Resident compliance was high, with 88% using APL for at least 90% of procedures, and only 4% of eligible procedures logged manually post-APL.

Conclusions:

• Implementation of the APL system led to a substantial increase in the number of procedures logged by EM residents.
• The APL system significantly improved the completeness and accuracy of procedure documentation.
• This innovative APL system enhances the assessment of resident competencies, including Patient Care and Practice-Based Learning, as defined by the ACGME.