Supracondylar Humeral Fracture Documentation: A Performance Improvement Study

Area of Science:

• Pediatric Orthopedics
• Health Informatics
• Medical Documentation

Background:

• Supracondylar humerus fractures (SCH) are common pediatric elbow fractures requiring operative stabilization.
• Proper documentation is critical for patient care and legal defense, especially during the transition to electronic medical records (EMR).
• Initial evaluations revealed suboptimal documentation for SCH cases.

Purpose of the Study:

• To develop and implement an EMR protocol to enhance documentation for pediatric SCH.
• To streamline care and improve the quality of medical records for these fractures.

Main Methods:

• A clinical pathway was implemented to standardize documentation processes.
• Documentation rates were compared before (retrospective) and after (prospective) pathway implementation.
• Statistical analysis, including chi-squared and Fisher exact tests, was used to assess significance.

Main Results:

• Significant improvements in documentation were observed for nursing preoperative, physician preoperative, and physician postoperative records.
• Trends toward improvement were noted in postanesthesia care unit, nursing postoperative, and physician clinic follow-up, but did not reach statistical significance.
• Ideal 100% documentation was not achieved in all categories despite overall improvements.

Conclusions:

• The clinical pathway significantly improved physician and nursing documentation for pediatric SCH within the EMR system.
• While the pathway demonstrated effectiveness, specific areas within the EMR require further refinement to achieve complete documentation.
• Enhanced documentation is vital for quality patient care and medical-legal defense.