Increased adolescent overweight and obesity documentation through a simple electronic medical record intervention

The purpose of this project was to improve provider documentation of adolescent overweight and obesity through body mass index percentile (BMI%) documentation in the military's electronic medical record (EMR).

Using the FOCUS-PDCA (Find-Organize-Clarify-Understand-Select-Plan-Do-Check-Act) model, we developed an intervention to improve rates of diagnosis of overweight/obesity in our adolescent medicine clinic. Medical technicians documented the patient's BMI% and growth chart in the EMR. Pre- and postintervention chart reviews of approximately 300 consecutive patient encounters compared the rates of overweight/obesity with provider-documented diagnosis.

A total of 333 pre- and 328 postintervention clinic encounters were reviewed. The rate of overweight and obesity calculated was similar between pre- and postintervention groups (30% vs. 31%). Correct diagnosis increased from 40% to 64% after the intervention. Females and patients seen by resident physicians were less likely to receive a correct diagnosis at baseline, but these differences were mitigated in the postintervention group. In multivariate analyses, only the intervention and provider type were predictive of an improvement in correct diagnosis.

BMI% documentation in our EMR was an effective way to improve documentation of overweight/obese adolescent patients and may be particularly helpful for resident physicians.