Background: While the electronic health record (EHR) provides many benefits, its use can easily allow for incomplete documentation of relevant historical information. The EHR is designed to store documentation of a patient’s past medical history (PMH), surgical history (PSH), family history (FH), and active hospital problems in the History tab. When the information is in the History tab, it can be hyperlinked, or pulled directly, into history and physical (H&P) notes using a SmartLink; however, if no history is stored in the tab, the SmartLink will be empty and result as “no history on file” being documented in the H&P (Figure 1a). These empty SmartLinks highlight missed opportunities to have complete and accurate H&P documentation, an important component of patient care. Baseline data at our institution showed high rates of incomplete documentation of a patient’s PMH, PSH, FH, and active hospital problems within the EHR. The aim of our project was to decrease the incidence of “no PMH/PSH/FH on file” and “no active hospital problems” being documented in pediatric hospital medicine (PHM) H&P notes to less than 5% over 4 months.
Methods: We use quality improvement methodology to implement and test interventions designed to achieve our aim. We included 1129 patient encounters admitted to the PHM resident teams between 3/1/21 and 6/30/21. Interventions included creating and incorporating a clinical decision support (CDS) tool into the PHM H&P template that would display a SmartLink with a wildcard (***), also known as a hard stop, if no history was documented in the History tab (Figure 1b). This prevented a provider from signing the note until the wildcard was addressed by documenting the missing content. The CDS tool also encouraged proper documentation of history by providing a direct link to the History tab. Subsequent interventions included reminding residents to use the templates at housestaff meetings and via email. The outcome measure was the percent of H&P’s with “no PMH/PSH/FH on file” and “no active hospital problems”. Our process measure was the percentage of H&Ps that used the PHM H&P note template which contained our CDS tool. Our balancing measure was the percent of notes that free texted FH as “none” rather than documentation of pertinent FH positives or negatives. This workaround would allow a provider to sign an H&P with incomplete documentation, but still avoids “no FH on file”.
Results: Baseline data showed an incidence of “no PMH/PSH/FH on file” and “no active hospital problems” in resident PHM H&P notes as 7.9%, 18.7%, 8.3%, and 17.0% respectively. After the intervention of the CDS tool, special cause variation was seen with improvement to 1.2%, 2.2%, 2.9%, and 4.2% respectively (Figure 2). Our process measure, utilization of the PHM H&P note template, remained high at 87.2% without special cause variation. No changes in the balancing measure noted.
Conclusions: The creation of a simple CDS tool within the PHM H&P note templates was associated with a decreased incidence of “no PMH/PSH/FH on file” and “no active hospital problems”, surpassing our goal of < 5%. This increased the quality of our H&P documentation. Resident utilization of PHM H&P templates was already high, but reminders did not further increase its use. Our balancing measures were unaffected. Future interventions include emphasizing the use of the PHM H&P templates with incoming residents to further culture change and incorporating this CDS tool into note templates outside of PHM.