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Evaluation and Improvement of Intern Progress Note Assessments and Plans
Michelle M Kelly1, Daniel J Sklansky2, Kirstin A M Nackers2
1Departments of Pediatrics and michelle.kelly@wisc.edu.
Hospital Pediatrics
|March 11, 2021
Summary
A new tool and intervention improved intern progress note quality and efficiency. The progress note assessment and plan evaluation (PNAPE) tool demonstrated high reliability, enhancing documentation without increasing time.
Area of Science:
- Medical Informatics
- Healthcare Quality Improvement
- Medical Education
Background:
- Electronic health records have raised concerns about the declining quality of provider progress notes.
- Assessing and improving the quality of intern progress notes is crucial for patient care and medical training.
Purpose of the Study:
- To develop a reliable tool for evaluating progress note assessments and plans.
- To determine if a bundled intervention improves intern note quality without extending documentation time.
Main Methods:
- A 19-item progress note assessment and plan evaluation (PNAPE) tool and intervention were developed.
- Interrater reliability was assessed using the intraclass correlation coefficient.
- Blinded assessors evaluated pre- and postintervention notes using the PNAPE tool.
Main Results:
- The PNAPE tool demonstrated high interrater reliability (ICC = 0.86).
- Median PNAPE scores significantly increased postintervention (P = .008).
- Median note file time significantly decreased postintervention (P < .001).
Conclusions:
- The PNAPE tool is reliable for assessing progress note quality.
- A bundled intervention may improve intern note quality and efficiency.
- Further research is needed to confirm sustained improvements in other settings.
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