Departments of Pediatrics and
Departments of Pediatrics and.
Hosp Pediatr. 2021 Apr;11(4):401-405. doi: 10.1542/hpeds.2020-003244. Epub 2021 Mar 10.
Progress notes communicate providers' assessments of patients' diagnoses, progress, and treatment plans; however, providers perceive that note quality has degraded since the introduction of electronic health records. In this study, we aimed to (1) develop a tool to evaluate progress note assessments and plans with high interrater reliability and (2) assess whether a bundled intervention was associated with improved intern note quality without delaying note file time.
An 8-member stakeholder team developed a 19-item progress note assessment and plan evaluation (PNAPE) tool and bundled intervention consisting of a new note template and intern training curriculum. Interrater reliability was evaluated by calculating the intraclass correlation coefficient. Blinded assessors then used PNAPE to evaluate assessment and plan quality in pre- and postintervention notes (fall 2017 and 2018).
PNAPE revealed high internal interrater reliability between assessors (intraclass correlation coefficient = 0.86; 95% confidence interval: 0.66-0.95). Total median PNAPE score increased from 13 (interquartile range [IQR]: 12-15) to 15 (IQR: 14-17; = .008), and median file time decreased from 4:30 pm (IQR: 2:33 pm-6:20 pm) to 1:13 pm (IQR: 12:05 pm-3:59 pm; < .001) in pre- and postintervention notes. In the postintervention period, a higher proportion of assessments and plans indicated the primary problem requiring ongoing hospitalization and progress of this problem ( = .0016 and < .001, respectively).
The PNAPE tool revealed high reliability between assessors, and the bundled intervention may be associated with improved intern note assessment and plan quality without delaying file time. Future studies are needed to evaluate whether these improvements can be sustained throughout residency and reproduced in future intern cohorts and other inpatient settings.
病程记录用于传达医疗服务提供者对患者诊断、病情进展和治疗计划的评估；然而，提供者认为自电子健康记录引入以来，病程记录的质量已经下降。本研究旨在：（1）开发一种评估病程记录评估和计划的工具，其具有较高的组内一致性；（2）评估捆绑干预措施是否与改善住院医师记录质量而不延迟记录归档时间相关。
一个由 8 名利益相关者组成的团队开发了一个 19 项的病程记录评估和计划评估工具（PNAPE）和捆绑干预措施，包括新的记录模板和住院医师培训课程。采用组内相关系数评估组内一致性。然后，盲法评估者使用 PNAEP 评估干预前后记录（2017 年秋季和 2018 年秋季）中的评估和计划质量。
PNAPE 显示评估者之间具有较高的内部组内一致性（组内相关系数=0.86；95%置信区间：0.66-0.95）。PNAPE 的总中位数评分从 13（四分位距 [IQR]：12-15）增加到 15（IQR：14-17； =.008），文件归档时间中位数从 4:30 pm（IQR：2:33 pm-6:20 pm）减少到 1:13 pm（IQR：12:05 pm-3:59 pm； <.001）。在干预后期间，更多的评估和计划表明需要持续住院的主要问题以及该问题的进展（ =.0016 和 <.001，分别）。
PNAPE 工具显示评估者之间具有较高的可靠性，捆绑干预措施可能与改善住院医师记录评估和计划质量相关，而不会延迟文件归档时间。需要进一步的研究来评估这些改进是否可以在整个住院医师培训期间持续，并在未来的住院医师群体和其他住院环境中重现。
