Smalley Courtney M, Gourash Molly, Rooney Brittany, Mastrangelo Drew, Muir McKinsey R, Steppenbacker Cynthia, Simon Erin L, Ruwe Jeffrey
Department of Emergency Medicine, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America.
Department of Emergency Medicine, Cleveland Clinic Health System, Cleveland, OH, United States of America.
Am J Emerg Med. 2025 Aug;94:188-191. doi: 10.1016/j.ajem.2025.04.062. Epub 2025 Apr 28.
Point-of-care ultrasound (POCUS) is a common modality utilized in emergency departments (EDs). Image acquisition and storage workflows have significantly improved. Saving POCUS images is considered standard of care. However, documentation compliance is a struggle for clinicians in the chaotic ED environment. We sought to implement a simple electronic medical record (EMR) deficiency workflow to improve capture of POCUS documentation and billing in a large healthcare setting.
A retrospective review of all POCUS studies across 12 EDs was performed from January 1 to December 31, 2023. All EDs utilized the same EMR with standardized workflow. Clinicians were recommended to complete charting within 48 h of patient disposition. A POCUS deficiency workflow was implemented on June 1, 2023 to improve compliance. Deficiency workflow was defined as automated in-basket messaging that appeared after POCUS order entry. Deficiency remained in the clinicians in-basket until procedure note was completed. We compared POCUS chart deficiencies for lack of procedural documentation. Descriptive statistics were performed.
5013 POCUS were reviewed during the study period, 42 % before and 58 % after implementation. There was a 3.0 % absolute reduction (CI 2.01 %, 3.97 %) in procedure note deficiency from the pre-intervention to post-intervention period, 4.44 %. to 1.45 %.
A POCUS deficiency workflow improved documentation across our healthcare system. This directly improved billing of POCUS studies and decreased late chart notifications. This workflow can be implemented in any medical specialty that utilizes POCUS. We recommend large healthcare systems investigate similar workflows to improve documentation and billing of POCUS exams.
床旁超声（POCUS）是急诊科常用的一种检查方式。图像采集和存储流程已得到显著改善。保存POCUS图像被视为医疗标准。然而，在急诊科混乱的环境中，临床医生在文件记录合规方面面临困难。我们试图实施一种简单的电子病历（EMR）缺陷工作流程，以改善在大型医疗机构中POCUS文件记录的获取和计费情况。
对2023年1月1日至12月31日期间12个急诊科的所有POCUS检查进行回顾性分析。所有急诊科都使用相同的带有标准化工作流程的电子病历。建议临床医生在患者出院后48小时内完成病历记录。2023年6月1日实施了POCUS缺陷工作流程以提高合规性。缺陷工作流程定义为在POCUS订单录入后出现的自动收件篮消息。在完成检查记录之前，缺陷一直保留在临床医生的收件篮中。我们比较了因缺乏检查记录而导致的POCUS病历缺陷情况。进行了描述性统计。
在研究期间共审查了5013次POCUS检查，实施前占42%，实施后占58%。从干预前期到干预期，检查记录缺陷的绝对减少率为3.0%（置信区间2.01%，3.97%），从4.44%降至1.45%。
POCUS缺陷工作流程改善了我们医疗系统中的文件记录情况。这直接改善了POCUS检查的计费情况，并减少了病历延迟通知。此工作流程可在任何使用POCUS的医学专科中实施。我们建议大型医疗系统研究类似的工作流程，以改善POCUS检查的文件记录和计费情况。
