Kulkarni Deepa, Heath Jayme, Kosack Amanda, Jackson Nicholas J, Crummey Audrey
Mattel Children's Hospital and
Mattel Children's Hospital and.
Hosp Pediatr. 2018 Jul;8(7):430-435. doi: 10.1542/hpeds.2017-0163.
Diagnoses extracted from physician notes are used to calculate hospital quality metrics; failure to document high-risk diagnoses may lead to the appearance of worse-than-expected outcomes for complex patients. Academic hospitals often rely on documentation authored by trainees, yet residents receive little training in this regard. In this study, we evaluate inpatient pediatric resident notes to determine which high-risk diagnoses are commonly missed and assess the efficacy of a multitiered intervention to improve the documentation of these diagnoses.
In a baseline review of 220 charts, 13 frequently missed high-risk diagnoses were identified in 2013. Interventions began in 2014, including physician education and reference cards. The intervention also included note template prompts for 4 of the diagnoses. Using a standardized rubric, we reviewed charts for 3 years (2013, 2014, and 2015). The average within-disease probability of missed high-risk diagnoses was compared across time.
There was a decrease in the probability of undocumented target high-risk diagnoses after the intervention (52% vs 36% in 2014 [odds ratio = 0.51; < .001] and 37% in 2015 [odds ratio = 0.50; < .001]). Documentation of diagnoses prompted by the note template was not significantly better than those targeted by the other interventions alone ( = .55).
Pediatric residents were significantly less likely to omit a high-risk diagnosis in their notes after implementation of our documentation improvement program, suggesting that curriculum development is an effective method of improving documentation, with the goal of improving the accuracy of health systems performance indices.
从医生记录中提取的诊断用于计算医院质量指标；未能记录高风险诊断可能导致复杂患者的结果比预期更差。学术医院通常依赖实习生撰写的记录，但住院医师在这方面接受的培训很少。在本研究中，我们评估儿科住院医师的住院记录，以确定哪些高风险诊断经常被遗漏，并评估多层干预措施对改善这些诊断记录的效果。
在对220份病历的基线审查中，2013年确定了13种经常被遗漏的高风险诊断。干预措施于2014年开始，包括医生教育和参考卡片。干预措施还包括针对其中4种诊断的记录模板提示。我们使用标准化的评分标准，对2013年、2014年和2015年这3年的病历进行了审查。比较了不同时间遗漏高风险诊断的疾病内平均概率。
干预后未记录的目标高风险诊断的概率有所下降（2014年为52%对36%[优势比=0.51；P<.001]，2015年为37%[优势比=0.50；P<.001]）。记录模板提示的诊断记录并不比仅通过其他干预措施针对的诊断记录显著更好（P=.55）。
在实施我们的记录改进计划后，儿科住院医师在其记录中遗漏高风险诊断的可能性显著降低，这表明课程开发是提高记录质量的有效方法，目标是提高卫生系统绩效指标的准确性。
