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Updated: Dec 18, 2025

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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Implementing standardized provider documentation in a tertiary epilepsy clinic.

Felipe J S Jones1, Jason R Smith2, Neishay Ayub2

  • 1From the Department of Neurology (F.J.S.J., J.R.S., N.A., S.S.C., D.B.H., L.M.V.R.M.), Massachusetts General Hospital, Harvard Medical School; Department of Neurology (S.T.H.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Pediatrics (J.R.B.), Cumming School of Medicine, University of Calgary, Alberta, Canada; and Research and New Therapies (B.E.F.), Epilepsy Foundation, Landover, MD. felipe.jones@mgh.harvard.edu.

Neurology
|June 18, 2020
PubMed
Summary

Standardized documentation in epilepsy clinics improved data collection. However, 18.5% of patients disagreed with their epilepsy diagnosis, showing a need for better patient-provider communication.

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Area of Science:

  • Neurology
  • Clinical Informatics
  • Quality Improvement

Background:

  • Standardized documentation is crucial for effective epilepsy care.
  • Patient perception of diagnosis can differ from provider documentation.

Purpose of the Study:

  • To implement standardized documentation in an epilepsy clinic.
  • To compare patient perception of epilepsy diagnosis with provider records.

Main Methods:

  • Quality improvement methodology was used to increase documentation rates.
  • An interactive SmartPhrase tool mirrored a documentation template.
  • Statistical process control charts assessed SmartPhrase completion.

Main Results:

  • SmartPhrase completion reached a median of 78%.
  • 18.5% of patients disagreed with their epilepsy diagnosis (κ = 0.13).
  • Disagreement was not linked to sociodemographic or clinical factors.

Conclusions:

  • Standardized documentation is feasible in tertiary epilepsy clinics.
  • A significant gap exists in patient-provider agreement on epilepsy diagnosis.
  • Improved patient-provider communication is needed.