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Design and Implementation of Structured Clinical Documentation Support Tools for Treating Stroke Patients
Kelly Claire Simon1, Richard Munson1, Archie Ong1
1Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois.
A new electronic medical record (EMR) toolkit standardizes stroke care documentation to align with best practices, improving quality improvement and research initiatives for stroke patients.
Area of Science:
- Neurology
- Medical Informatics
- Clinical Documentation
Background:
- Standardized electronic medical record (EMR) tools offer efficient care aligned with Best Practices.
- EMR tools support quality improvement and practice-based research initiatives.
Purpose of the Study:
- To develop a customized structured clinical documentation toolkit for stroke patient care.
- To standardize patient data collection for Best Practices in stroke treatment.
Main Methods:
- Developed a structured clinical documentation toolkit for EMR systems.
- Toolkit standardizes collection of demographic data, scores, disability, treatment, and outcomes for stroke patients.
Main Results:
- Created and implemented the EMR toolkit.
- Evaluated 2332 patients for stroke since August 1, 2018.
- Demonstrated toolkit utility in collecting data for quality care and research.
Conclusions:
- Developed an EMR toolkit to support Best Practices in stroke care.
- Discussed quality improvement and research initiatives utilizing the toolkit.
- Shared the toolkit with other Neurology Departments via the Neurology Practice-Based Research Network.
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