Use of a structured encounter form to improve well-child care documentation.

OBJECTIVE

To determine if a structured encounter form for well-child care improves documentation of well-child care.

DESIGN

Retrospective medical record review of a before-and-after trial.

SETTING

Family practice residency clinic serving a primarily low-socioeconomic urban population.

PATIENTS

Children younger than 6 years receiving well-child care visits.

INTERVENTION

Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force.

MAIN OUTCOME MEASURES

Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form.

RESULTS

A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form.

CONCLUSIONS

The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.