BACKGROUND

Procedural experience for residents and fellows is critical for achieving competence, and documentation of procedures performed is required. Procedure logs serve as the record of this experience, but are commonly generated manually, require substantial administrative effort, and cannot be corroborated for accuracy.

OBJECTIVE

We developed and implemented a structured clinical-educational report template (CERT), which automatically generates procedure logs directly from the clinical record.

METHODS

Our CERT aimed to replace the post-procedure note template for our cardiac catheterization laboratory and was incorporated into the electronic health record system. Numbers of documented procedures in automated CERT-derived procedure logs over a 1-year post-intervention period (2018-2019) were compared to manual logs and corrected for clinical volume changes. The CERT's impact on fellowship experience was also assessed.

RESULTS

Automated CERT procedure logs increased weekly procedural documentation over manual procedure logs for total procedures (24.2 ± 6.1 vs 17.1 ± 6.8, = .007), left heart catheterizations (14.5 ± 3.6 vs 10.8 ± 4.2, = .039), total procedural elements (40.2 ± 11.4 versus 20.9 ± 12.5, < .001), and captured procedural details not previously documented. The CERT also reduced self-reported administrative time and improved fellowship experience.

CONCLUSIONS

A novel CERT allows procedure logs to be automatically derived from the clinical record and increased the number of documented procedures, compared to manual logging. This innovation ensures an accurate record of procedural experience and reduces self-reported non-educational administrative time for cardiology fellows.