Background:
The daily progress note is the foundation of inpatient documentation and communication for healthcare providers. With the advent of the electronic medical record, copy-and-pasting, note bloat, inconsistencies, erroneous data, and lack of cognitive processing have become widespread leading to difficult to read and inaccurate progress notes.
Purpose:
At Bassett Medical Center, it was determined through a survey of both attending and resident physicians that progress notes: 1) do not reflect the thought process of the clinician; 2) are not up-to-date and do not communicate the current state of the patient; 3) are not internally consistent making the data untrustworthy; and 4) are too long and cluttered. In response to these challenges, we developed a documentation improvement project to help improve these factors. A previous improvement project had shown that developing a standardized note template can drive note writing behavior and therefore was a major component of our project.
Description:
Our project included the development of a progress note template, note writing guidelines with small group training, and frequent healthcare provider feedback. Our training program also included video guides, live workshops, and reviews of documentation by attending physicians and medical coders.
The project was piloted on one teaching medical team and subsequently spread to all five teaching medical teams after a positive response. To measure improvement, 8 sequential pairs of inpatient progress notes prior to and after the project implementation were graded using a 7-point system. The scoring system included the following elements: assessment of the primary problem, being up-to-date and succinct, and consistency. Our goal was to improve the average overall score of a progress note by at least 2 points within 1 year.
The average score of notes prior to project launch was 2.81 (SD 0.09), which improved to an average score of 5.88 (SD 0.53) out of 7 after. This represents an improvement by 3.07 points or approximately 109%. Incorporation of the clinician thought process and note succinctness improved the most. Rapid adoption of the template by the hospitalist group at our institution further supports the positive impact of the standardized template on documentation.
Conclusions:
Our quality improvement project illustrates that a template-based progress note along with sufficient training, is an effective way of improving the quality and clinical utility of progress notes. We believe feedback is a vital component in order to maintain effective incorporation of cognitive processing within the progress notes. A similar project could readily be introduced in other health systems.