A pilot study of the impact of an educational intervention aimed at improving medical record documentation

Farzandipour, Mehrdad; Meidani, Zahra; F, Rangraz Jeddi; Gilasi, Hamid Reza; L, Shokrizadeh Arani; Fakharian, Esmaeil; Saddik, Basema

doi:10.4997/jrcpe.2013.106

Cited by 23 publications

(20 citation statements)

References 22 publications

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“…Studies have shown that one-off measures are unlikely to result in sustainable change in healthcare provider behaviour. 23 Audit and feedback mechanism, supplemented by several measures including educational activities, appropriate incentives and disincentives, is likely to result in meaningful behavioural change. 24,25 A qualitative audit to ascertain the clinician acceptance and compliance with structured clinical proforma versus freehand case notes is recommended to guide the flexible design of the proforma in future.…”

Section: Discussionmentioning

confidence: 99%

Association between the introduction of a structured form and the quality of diabetes in pregnancy clinic care

Bahauddin

Sina

Simmons

2020

Internal Medicine Journal

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Background Pregnancy in women with pre‐gestational types 1 (T1DM) and 2 (T2DM) diabetes mellitus can be a clinical challenge. This study assessed the association between introducing a structured diabetes in pregnancy proforma, on the quality of medical record documentation and pregnancy outcomes in women with T1DM and T2DM. Aims To evaluate the impact of a proforma on the quality of documenting medical records and pregnancy/neonatal outcomes in women with pre‐gestational diabetes. Methods This was a retrospective two‐cycle audit: pre‐ and post‐proforma introduction. The documentation quality was assessed based on the rate of missing pre‐pregnancy/first trimester haemoglobin A1c (HbA1c), third trimester HbA1c, folate intake and dose, retinopathy and nephropathy progression. Changes in pregnancy outcomes were assessed by mode of delivery, preterm delivery, mean third trimester HbA1c, pre‐eclampsia and foetal outcomes. Results The pre‐ and post‐proforma periods included 91 and 41 pregnancies, respectively. The quality of documentation improved in the post‐proforma phase with the rate of missing data declining from 63.4% to 36.6% (P = 0.005) for pre‐pregnancy/first trimester HbA1c, 30.8% to 12.2% (P = 0.009) for periconceptional folate intake, 42.9% to 14.6% (P = 0.001) for folate dose, 100% to 31.7% (P < 0.001) for retinopathy progression, 92.3% to 19.5% (P < 0.001) for nephropathy progression and 31.9% to 7.3% (P = 0.016) for third trimester HbA1c. Macrosomia significantly reduced in the second cycle (49% vs 21% P = 0.003). Conclusion The quality of documentation improved significantly which is likely attributable to the implementation of the proforma. This study supports the use of structured documentation to reduce variation in care and potentially improve pregnancy outcomes.

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Section: Discussionmentioning

confidence: 99%

Association between the introduction of a structured form and the quality of diabetes in pregnancy clinic care

Bahauddin

Sina

Simmons

2020

Internal Medicine Journal

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“…As previous evidence debated that medical record documentation serves as less popular among HCPs; they believed to hinder the main responsibility (direct care of the patients) and superimpose on their workload. On the other hand, sharing the responsibility among different HCPs, including interns, residents, physicians and nurses, to register the medical documents may lead to inconsistency in the data ( 20 , 21 ).…”

Section: Discussionmentioning

confidence: 99%

Registry Data Coordinator (RDC): a Proper Accessible Strategy for Improving Road Traffic Injury (RTI) Hospital Based Trauma Registry Systems in Developing Countries and Low Income Countries

et al. 2018

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Introduction:Evidence suggested that a significant level of trauma mortality can be prevented using registry system. Aim:This study aimed to improve Kashan Hospital Based Trauma Registry System (KHBTRS) for Road Traffic Injury (RTI). Material and methods:After conducting focus group discussion absence of minimum data set (MDS) and poor data collection process (DCP) were identified as main problems for KHBTRS- RTI. Proposed MDS were surveyed by 20 experts of trauma research center of throughout the Iran. Then approved MDS applied for trauma registry system data base in form of SQL. DCP were reform from prospective data collection (review of medical record) to concurrent (through the interview) approach. Results:Most of participants for MDS approval belonged to clinical group 13(65%). 146 MDS in eighteen main categories were proposed for RTI. The maximum score for each MDS main categories were attributed to body parts injured 220 (100%) and patient vital signs 139 (99.29%) respectively. Pilot testing of KHBTRS- RTI database of 50 (50%) riders indicated fully completeness 50 (100%) for concurrent approach. It was concluded that based on experts’ viewpoints MDS relating to injury nature and place of occurrence have more priority in comparisons to MDS relating to causes of injury. It may attribute to health care providers focus on clinical care and treatment. Conclusion:It was concluded that based on experts’ viewpoints MDS relating to injury nature and place of occurrence have more priority in comparisons to MDS relating to RTI prevention; it may attribute to health care providers focus on clinical care and treatment. To develop injury interventions based on given data, recruitment of professionals as registry data coordinator with specific job description to collect and advocacy of injury external causes data seems imperative.

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“…Other studies have evaluated the impact of medical staff training on accurate and appropriate documentation and produced conflicting results. [17][18][19] Standardising medical records may potentially improve coding accuracy as shown in an audit conducted by the Royal College of Physicians in the UK. [20] Multicentre studies are required to test the impact of such interventions on coding accuracy.…”

Section: Discussionmentioning

confidence: 99%

Coding accuracy for Parkinson's disease hospital admissions: implications for healthcare planning in the UK

et al. 2017

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A pilot study of the impact of an educational intervention aimed at improving medical record documentation

Cited by 23 publications

References 22 publications

Association between the introduction of a structured form and the quality of diabetes in pregnancy clinic care

Association between the introduction of a structured form and the quality of diabetes in pregnancy clinic care

Registry Data Coordinator (RDC): a Proper Accessible Strategy for Improving Road Traffic Injury (RTI) Hospital Based Trauma Registry Systems in Developing Countries and Low Income Countries

Coding accuracy for Parkinson's disease hospital admissions: implications for healthcare planning in the UK

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