Toward more accurate documentation in neurosurgical care

Area of Science:

• Neurosurgery
• Healthcare Quality Improvement
• Clinical Documentation

Background:

• Accurate clinical documentation is essential for quality improvement and assessing healthcare changes.
• Limited literature exists on effective interventions to improve neurosurgical documentation accuracy and completeness.

Purpose of the Study:

• To share a single-institution experience with a two-part intervention aimed at enhancing clinical documentation among neurosurgery inpatient providers.
• To improve the accuracy and completeness of clinical documentation for neurosurgery inpatients.

Main Methods:

• A two-part intervention was implemented at an academic teaching hospital for neurosurgery residents and advanced practice providers (APPs).
• Intervention components included education on common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), and a shift from a system-based to a problem-based progress note template.
• A pre-post analysis compared CC/MCC capture rates for 12 months before and 3 months after the intervention.

Main Results:

• The CC/MCC capture rate for the neurosurgery service line increased from 62% in the preintervention period to 74% in the postintervention period.
• This increase was statistically significant (p = 0.00002).

Conclusions:

• Current clinical documentation practices by neurosurgical providers may underrepresent the complexity of neurosurgical inpatients regarding CCs/MCCs.
• An intervention combining education on prevalent CCs/MCCs with a problem-based progress note template can enhance the accuracy of patient acuity assessments.