Background: Patient record form one of the most important part of clinical care as the primary source for patient information for primary team, consultants, nurses and other paramedic staff and help in providing a higher quality of care, as well as monitoring patient safety. Incomplete patient records are a source of gaps in patient care and vice versa. The importance of clinical documentation in medico-legal cases cannot be more emphasized. The current American College of Graduate Medical Education has ruled that a first-year internal medicine resident must not be responsible for ongoing care of more than 10 patients at a time. This is a randomly assigned number and the implications have not been studied. Here we assess the quality of patient health documentation by first-year residents of a community teaching hospitals and evaluate how patient numbers and workload affect documentation quality.
Methods: Interns in the hospital go on-call for admissions every fourth day. 80 progress notes, four each from 20 interns on different call status were assessed. On an average, first-year residents or interns during the study period took care of 9±1 patients on a ‘post-call’ day, 7±1 patients on a ‘mid-call’ day, 5±1 on a ‘pre-call’ day and 4±1 on a ‘call’ day. Responsible Electronic Documentation Checklist is a validated checklist scoring system to assess the quality of progress notes. We calculated the average scores of progress notes based on the checklist and compared it to their call status to evaluate how the patient load affected documentation quality.
Results: The study found that notes were generally deficient in updated physical examination and summary statements while on days with maximum patient load there were minimal updates on assessment and plan, lacked a diagnostic plan for patient problems and physician interpretation of imaging studies. The average note scores dropped from 72.14% on a pre-call day to 57.06% on a post-call day. We found statistical significant difference in documentation quality between post-call day and any other call status and was most pronounced between the above two (p-value 0.00042; t=-3.626). We also found that a resident on average access patient charts 221.9 times a day during a floor-rotation which gives an impact of the electronic workload.
Conclusions: Apart from the patient load of the residents, other factors like physical stress from the previous call-day might also be affecting the documentation quality. How the deficiency in documentation quality has affected patient safety and litigations have to be further studied. Whether this can be extrapolated to hospitalists and consultants will also, be of interest. With the advent of electronic health records, the electronic workload and the ‘screen-time’ for the physicians have increased and this might add to resident burn-out.