Measuring medical residentsʼ chart-documentation practices

Moran, Maureena; Wiser, Thomas H.; Nanda, Joy P.; Gross, Herbert S.

doi:10.1097/00001888-198811000-00006

Cited by 18 publications

(20 citation statements)

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“…Although no prior studies have comprehensively examined the correlates of medical record documentation quality in the primary care setting, one small study measured medical residents' chart-documentation practices [24]. That study of 26 medical records suggested that documentation was more complete in charts of male patients than in female patients, a finding not confirmed in the present study.…”

Section: Discussioncontrasting

confidence: 68%

Quality and correlates of medical record documentation in the ambulatory care setting

Soto

Kleinman

Simon

2002

BMC Health Serv Res

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Background: Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record.

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Section: Discussioncontrasting

confidence: 68%

Quality and correlates of medical record documentation in the ambulatory care setting

Soto

Kleinman

Simon

2002

BMC Health Serv Res

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“…Our study is limited by relying on chart abstraction data to assess the process of informed consent. 12 Further, our research findings may not reflect current practice given that the study period was between 1996 and 1998.…”

Section: Discussionmentioning

confidence: 77%

Informed Consent for Thrombolytic Therapy for Patients With Acute Ischemic Stroke Treated in Routine Clinical Practice

Rosenbaum

Bravata²,

Concato³

et al. 2004

Stroke

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Background and Purpose— Little is known about informed consent for tissue plasminogen activator (tPA). Our objectives were to determine how frequently informed consent is obtained when tPA is given to stroke patients in clinical practice and whether the person providing consent (patient or surrogate) was the appropriate decision-maker. Methods— This retrospective cohort included acute stroke patients given tPA in 10 Connecticut hospitals (1996–1998). Consent was defined as any documentation of discussion about risks and benefits of tPA. Patients had adequate decision-making capacity if they were alert, oriented, and without aphasia or neglect (patient was appropriate decision-maker). Patients with any of these deficits were considered to have diminished capacity (surrogate was appropriate decision-maker). Results— Among 63 patients who received tPA, 53 (84%) had informed consent documented; 16/53 (30%) gave their own consent. Among patients with adequate decision-making capacity, 5/8 (63%) had consent by surrogate. Among patients with diminished capacity, 7/38 (18%) provided their own consent. Conclusions— A substantial percentage of patients who received tPA for stroke had no consent documented. Surrogates often provided consent when the patients had capacity; conversely, patients with diminished capacity sometimes provided their own consent. Given the urgency and weight of the decision regarding tPA, more explicit informed consent and capacity assessment should be considered for treatment protocols.

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“…This study demonstrated that residents in their second year produced better documentation than did first-year residents. This study inferred that knowledge and experiential teaching play a role in chart-documentation practices [9]. Another study by Carroll et al [10] demonstrates that daily progress notes written by resident physicians in the neonatal ICU often contain inaccurate, or omit, pertinent information.…”

Section: Introductionmentioning

confidence: 93%

“…A previous study examined videotaped recordings of resident/patient encounters and medical documentation [9]. This study demonstrated that residents in their second year produced better documentation than did first-year residents.…”

Section: Introductionmentioning

confidence: 99%

An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients

et al. 2012

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IntroductionIncreasing antimicrobial costs, reduced development of novel antimicrobials, and growing antimicrobial resistance necessitate judicious use of available agents. Antimicrobial stewardship programs (ASPs) may improve antimicrobial use in intensive care units (ICUs). Our objective was to determine whether the introduction of an ASP in an ICU altered the decision to treat cultures from sterile sites compared with nonsterile sites (which may represent colonization or contamination). We also sought to determine whether ASP education improved documentation of antimicrobial use, including an explicit statement of antimicrobial regimen, indication, duration, and de-escalation.MethodsWe retrospectively analyzed consecutive patients with positive bacterial cultures admitted to a 16-bed medical-surgical ICU over 2-month periods before and after ASP introduction (April through May 2008 and 2009, respectively). We evaluated the antimicrobial treatment of positive sterile- versus nonsterile-site cultures, specified a priori. We reviewed patient charts for clinician documentation of three specific details regarding antimicrobials: an explicit statement of antimicrobial regimen/indication, duration, and de-escalation. We also analyzed cost and defined daily doses (DDDs) (a World Health Organization (WHO) standardized metric of use) before and after ASP.ResultsPatient demographic data between the pre-ASP (n = 139) and post-ASP (n = 130) periods were similar. No difference was found in the percentage of positive cultures from sterile sites between the pre-ASP period and post-ASP period (44.9% versus 40.2%; P = 0.401). A significant increase was noted in the treatment of sterile-site cultures after ASP (64% versus 83%; P = 0.01) and a reduction in the treatment of nonsterile-site cultures (71% versus 46%; P = 0.0002). These differences were statistically significant when treatment decisions were analyzed both at an individual patient level and at an individual culture level. Increased explicit antimicrobial regimen documentation was observed after ASP (26% versus 71%; P < 0.0001). Also observed were increases in formally documented stop dates (53% versus 71%; P < 0.0001), regimen de-escalation (15% versus 23%; P = 0.026), and an overall reduction in cost and mean DDDs after ASP implementation.ConclusionsIntroduction of an ASP in the ICU was associated with improved microbiologically targeted therapy based on sterile or nonsterile cultures and improved documentation of antimicrobial use in the medical record.

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Measuring medical residentsʼ chart-documentation practices

Cited by 18 publications

References 0 publications

Quality and correlates of medical record documentation in the ambulatory care setting

Quality and correlates of medical record documentation in the ambulatory care setting

Informed Consent for Thrombolytic Therapy for Patients With Acute Ischemic Stroke Treated in Routine Clinical Practice

An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients

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