Improving Documentation Timeliness: A "Brighter Future" for the Electronic Medical Record in Resident Clinics

Electronic medical records have many observed benefits but may cause work disruption, resulting in delayed documentation completion. The purpose of this project was to improve compliance with institutional standards of documentation of well child checks for residents and attendings without increasing stress.

This project was completed at Children's Hospital Primary Care Clinic at Vanderbilt, which is staffed by 74 residents, supervised by 17 attendings. A longitudinal observational study using convenience sampling for the last full week of each month from October 2010-January 2012 was planned. Baseline documentation completion rates were assessed, then age-specific, structured data-entry forms were introduced beginning in March 2011. Run charts were created for completion data for all clinic visits in the sample. Physician self-report of satisfaction with and stress related to documentation was assessed through pre- and postintervention surveys.

Data were derived for an average of 231 patient visits per month. The median percentage of documentation or attestations completed within the institutional standards increased from 54.7% to 78.9% for residents and from 38.2% to 83.5% for attendings. Physicians reporting high satisfaction with documentation increased from 20.5% to 85.7% (P < .01) for residents and from 11.1% to 76.9% (P < .01) for attendings. Residents reporting high stress with documentation decreased from 59.1% to 28.6% (P < .02).

Use of age-specific, structured data-entry forms achieved marked improvement in documentation timeliness, but there is still room for improvement. The authors are now teaching computer-based documentation in exam rooms and instituting accountability measures.