Clinical Documentation Improvement: Transitioning to Neonatologist Driven Progress Notes

Abstract

Clinical Documentation Improvement: Transitioning to Neonatologist Driven Progress Notes Purpose: Our purpose was to implement a consistent documentation standard for a neonatology provider group including neonatal advanced practice providers (APP), neonatology fellows and neonatologists serving at a level four tertiary care Neonatal Intensive Care Unit (NICU). Primary outcomes included consistent note content, timeliness of note completion, and overall provider time spent in documentation. Secondary objectives included clinician satisfaction with the new standard and usefulness of the daily note to consulting services and other clinical team members Methods: …