1Department of Neurosurgery, Warren Alpert Medical School of Brown University; and.
2Department of Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Neurosurg Focus. 2021 Nov;51(5):E11. doi: 10.3171/2021.8.FOCUS21387.
Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service.
At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a "system-based" progress note template was changed to a "problem-based" progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention.
The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002).
Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.
准确的临床记录是任何质量改进努力的基础，因为在评估变化时，最终要衡量的是医疗记录。关于提高神经外科医务人员临床记录准确性和完整性的高影响力干预措施的文献有限。因此，作者旨在分享一项单机构经验，即通过神经外科住院服务实施两部分干预措施来增强临床记录的准确性。
在一家城市一级创伤、学术教学医院，对住院医师和高级实践提供者（APP）实施了两部分干预措施，以提高神经外科住院患者临床记录的准确性。住院医师和 APP 接受了医疗保险定义的最常见神经外科并发症或合并症（CC）和主要并发症或合并症（MCC）的指导。此外，将“基于系统的”病程记录模板更改为“基于问题的”病程记录模板。进行前后分析，比较干预前 12 个月和干预后 3 个月的 CC/MCC 捕获率。
神经外科科室的 CC/MCC 捕获率从干预前 12 个月的 62%上升到干预后 3 个月的 74%，这是一个显著的变化（p=0.00002）。
神经外科住院医师和 APP 现有的临床记录习惯可能无法捕捉到 CC/MCC 神经外科住院患者的程度。专注于最常见的 CC/MCC 并利用基于问题的病程记录模板的干预措施可能会导致更准确地评估神经外科患者的病情严重程度。
