Grogan Eric L, Speroff Theodore, Deppen Stephen A, Roumie Christianne L, Elasy Tom A, Dittus Robert S, Rosenbloom S Trent, Holzman Michael D
Department of Surgery, Vanderbilt University, Nashville, TN 37232-9485, USA.
J Am Coll Surg. 2004 Sep;199(3):468-75. doi: 10.1016/j.jamcollsurg.2004.05.254.
Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications.
Surgical residents and patients on three inpatient services were followed for a 1-year prospective cohort study. After a 6-month baseline period, a progress note template was developed and implemented for 6 months, and administrative data were retrieved. Residents were given three case examinations assessing documentation knowledge pre- and postintervention, and a satisfaction survey. Demographics, Charlson comorbidity score, ICD-9 codes, template-specific ICD-9 codes, All Patient Refined (APR)-DRG patient severity, DRG relative weight, predicted mortality (University Healthcare Consortium), pre- and postexam scores, and resident satisfaction were collected.
No difference in age, gender, race, or Charlson comorbidity score existed between pre- and postintervention patient groups. The length of stay decreased from 5.5 days to 4.8 days (p = 0.013). In the intervention group, total ICD-9 codes, template-specific ICD-9 codes, APR-DRG, DRG weight, and UHC predicted mortality had significant increases. Residents exposed to the progress note template improved their knowledge scores from 52% to 63% (p < 0.001), and 73% agreed that the progress note template was an improvement over handwritten notes. Residents not exposed to the progress note template did not improve their scores.
A progress note template improves documentation of comorbidities and complications, APR-DRG patient severity for benchmarking, and case-mix index, and increases patient-specific predicted mortality. The progress note template also improves surgical residents' documentation knowledge and satisfaction.
准确记录患者的合并症和并发症可改善病例组合的呈现、编码准确性以及用于基准比较的风险调整死亡率估计。我们假设一个包含合并症和并发症的病程记录模板将改善记录情况，并教会住院医师正确记录合并症和并发症。
对三个住院科室的外科住院医师和患者进行了为期1年的前瞻性队列研究。在为期6个月的基线期之后，开发并实施了一个病程记录模板，为期6个月，并检索了管理数据。在干预前后，对住院医师进行了三次病例检查，以评估其记录知识，并进行了满意度调查。收集了人口统计学信息、查尔森合并症评分、ICD-9编码、特定模板的ICD-9编码、所有患者精炼（APR）-诊断相关组（DRG）患者严重程度、DRG相对权重、预测死亡率（大学医疗联盟）、干预前后的考试成绩以及住院医师满意度。
干预前后的患者组在年龄、性别、种族或查尔森合并症评分方面没有差异。住院时间从5.5天降至4.8天（p = 0.013）。在干预组中，ICD-9编码总数、特定模板的ICD-9编码、APR-DRG、DRG权重和大学医疗联盟预测死亡率均有显著增加。接触病程记录模板的住院医师的知识得分从52%提高到了63%（p < 0.001），73%的人认为病程记录模板比手写记录有所改进。未接触病程记录模板的住院医师的分数没有提高。
病程记录模板改善了合并症和并发症的记录、用于基准比较的APR-DRG患者严重程度以及病例组合指数，并提高了患者特异性预测死亡率。病程记录模板还提高了外科住院医师的记录知识和满意度。
