Improved documentation and care planning with an asthma-specific history and physical

The objective was to determine the effect of an electronic asthma-specific inpatient history and physical (H&P) template on documented history and improvements in care plans.

This was a before-after comparison of history and care plan documentation following implementation of a new H&P template. The template was implemented in May 2011. A retrospective review of the electronic health record was completed for 304 consecutive patients (2-16 years of age) admitted for asthma June to September 2010 and 242 admitted June to September 2011. Elements reviewed included asthma severity classification, utilization history (previous oral steroids, emergency visits, hospitalizations, intensive care admissions, and intubations), and environmental history (exposure to cockroaches, rodents, and mold). Assessed changes in care plans included social work or asthma-related subspecialty consult and change in controller medications. Patients from 2011 were compared with those from 2010 by using ttest and chi2 statistics with adjustment for confounders by use of logistic regression. Interrupted time-series analyses assessed variability in documentation over time.

In 2011, the new H&P template was used in 74% of encounters. Compared with patients seen preimplementation, documentation in those seen after implementation was more likely to include severity classification (71% vs 44%; P < .0001), complete utilization history (73% vs 12%; P < .0001), and environmental history (66% v. 2%; P < .0001). Documentation became more consistent over time. Changes in care planning were also more common after implementation (63% vs 49%; P = .0006).

A structured H&P template for asthma led to more complete and less variable documentation of important history and likely led to enhancements in care plans.