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Improving documentation of quality measures in the electronic health record
1University of Michigan, Ann Arbor, Michigan.
Purpose:
Oncology quality measures provide an important tool to evaluate care received by cancer patients. These measures are frequently addressed by oncology nurse practitioners (NPs). NP documentation of quality oncology practice initiative (QOPI) measures in the electronic health record (EHR) is evaluated in this study.
Data Sources:
NP documentation of specific QOPI measures before and after an educational intervention (EI) was evaluated. EHR shortcuts, called "SmartPhrases," were used to increase efficiency in documentation of these measures.
Conclusions:
Preintervention chart audits found compliance <80% in the multiple measurement areas. Following the EI, NPs surveyed identified greater understanding of QOPI measures and an interest in using "SmartPhrases" to aid in measure documentation. The postintervention audit demonstrated improvement in all areas addressed during the EI noting the use of "SmartPhrases" based on descriptive findings.
Implications For Practice:
NPs play a significant role in providing quality care for oncology patients. By increasing knowledge related to the documentation of quality measures and providing tools to increase the efficiency associated with their documentation, a positive impact can be made in efforts to promote quality patient care.
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