J Hosp Med. 2022 Jan;17(1):28-35. doi: 10.1002/jhm.27410.
ABSTRACT
BACKGROUND: Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown.
OBJECTIVE: The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality.
DESIGNS: Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention.
SETTINGS AND PARTICIPANTS: Admission notes written by University of Cincinnati interns were assessed.
INTERVENTIONS: The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback.
MAIN OUTCOMES AND MEASURES: Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT).
RESULTS: Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (β = .08, p = .03 and β = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time.
CONCLUSION: Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.
PMID:35504574 | DOI:10.1002/jhm.27410
