Effectiveness of Best‐Practice Guidelines in Improving Resident Progress Notes in an Ehr

Background:

Although legibility and accessibility are advantages to documenting in the electronic health record (EHR), providers nationally have observed a decline in the quality of provider documentation after implementing an EHR. Concerns include: “note bloat” (overinclusion of data leading to lengthy, unreadable notes), copy and paste, loss of the narrative, and a perceived loss of cognitive processing with the use of templates. Despite the issues reported with EHR documentation, there are only a few studies addressing the need to improve the quality of notes. To address these concerns, providers at 2 academic centers developed and implemented a set of “Best Practices for Writing Inpatient Progress Notes.” The objective of this study is to evaluate the effectiveness of our implementation by evaluating resident notes written before and after establishing these guidelines. We hypothesize that the quality of resident progress notes, as measured by compliance with the best practices, will improve after implementing the guidelines.

Methods:

In this ongoing study, we examined notes written by pediatric interns before (preintervention group) and after (postintervention group) the establishment of best‐practice guidelines. The postintervention group received training about the guidelines and was instructed to use a corresponding note template at site 1. At site 2, preexisting templates underwent minor changes to achieve compliance with the guidelines. Eligible notes were evaluated utilizing a scoring tool (Fig. 1) that measures compliance with the guidelines. In this preliminary study, notes were scored by each site's PI. The mean and median scores from the pre‐ and postintervention periods were determined at each institution. A two‐sample t test was performed for comparisons between the pre‐ and postinterventions at each location. Two‐way analysis of variance was performed for the comparison between pre‐ and postinterventions for the combined analysis.

Results:

Preliminary results are based on the evaluation of 5 notes in both the pre‐ and post groups at each site. At site 1, there was a statistically significant increase in the note score between the pre‐ and post groups (13.4 ± 0.55 vs. 15.2 ± 1.64, P = 0.049). At site 2, no statistically significant increase in the note score between the pre‐ and post groups was detected.

Conclusions:

Early results at 1 site indicate that best‐practice guidelines for writing notes in the EHR may be effective in improving the quality of inpatient progress notes. Less change was noted at the second site. This may have been affected by the existence of note templates already in close compliance with the guidelines. Ongoing evaluation of the differences in implementation of the guidelines between the 2 centers is needed. A larger sample size is also needed to provide enough power to detect change. Interrater reliability in scoring the notes must also be established among raters at each site and between the 2 sites.

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Best‐practice guidelines audit tool.