The Empty SmartLink Solution: A Quality Improvement Initiative to Improve History and Physical Notes Documentation...

Area of Science:

• Quality Improvement
• Clinical Informatics
• Pediatric Healthcare

Background:

• Structured documentation in discrete fields is crucial for medical decision-making, research, and quality improvement.
• Incomplete documentation, indicated by 'empty' fields for past medical history (PMH), past surgical history (PSH), family history (FH), and active hospital problems (AHP), poses a significant challenge.

Purpose of the Study:

• To decrease the incidence of "no PMH/PSH/FH/AHP on file" in history and physical (H&P) notes at a children's hospital.
• The specific aim was to reduce these omissions from baseline rates (7.9%, 18.7%, 8.3%, 17.0%) to below 5% within 4 months.

Main Methods:

• A multidisciplinary team employed quality improvement methodology for pediatric hospital medicine encounters.
• Interventions included a clinical decision support tool with a hard stop in H&P templates and documentation education.
• Statistical process control charts were used to monitor outcome measures (percentage of H&Ps with missing data) and process measures (template use).

Main Results:

• The incidence of "no PMH/PSH/FH/AHP on file" significantly decreased to 1.2%, 2.2%, 2.9%, and 4.2%, respectively, demonstrating special cause variation.
• H&P template utilization remained high at 87.2% throughout the study period.

Conclusions:

• A simple clinical decision support tool effectively reduced the occurrence of incomplete discrete documentation, meeting the study's objective.
• This approach highlighted the efficacy of automated clinical decision support over reliance on education alone for driving change.
• Future efforts will focus on expanding hard stops to other documentation areas and ensuring sustained improvements.