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The Effects of an Electronic Medical Record Prompt on Documentation of Firearm Screening in and Adolescent Primary
1Section of Adolescent Medicine, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado.
Purpose:
There is limited evidence as to how to facilitate health care providers (HCPs) addressing firearm injury prevention during routine visits. The purpose of this project was to examine whether including a screening question about firearms in the home in the routine care template increases the screening of youth access to firearms.
Methods:
A pre-post approach chart review was conducted for youth 12-21 years old. Outcomes included HCP documentation of screening for the presence of firearms and whether counseling caregivers on safer storage practices was delivered.
Results:
HCPs documented screening adolescents for firearms 85% after the addition of the prompt compared to 25% prior to the change (p < .001). The presence of the screening prompt also led to an increase in the delivery of safe storage counseling (p = .035).
Discussion:
Altering the EMR template increased HCP documentation of the presence of firearms in the home while also increasing firearm injury prevention counseling delivered to caregivers.
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01:30Methods of Documentation VII: EMR
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Maintain Confidentiality and Security:
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:26Methods of Documentation II: POMR
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.