Improvement of Procedure Documentation Compliance With the Implementation of a Visual Aid

Abstract

BackgroundEmergency department (ED) providers face increasing task burdens and requirements related to documentation and paperwork. To decrease the mental task burden for providers, our institution developed an infographic that illustrates which forms are necessary for complete documentation of nonemergent invasive procedures. ObjectivesOur study aims to analyze the effect of a nonelectronic health record-based infographic, paired with direct feedback, on compliance with nonemergent invasive procedure documentation performed in the ED. MethodsThis was a retrospective, observational study of all procedure documentation performed in the ED with a pre-/post-test design. The study included two 8-month study periods, 1 year apart. The preimplementation period used for comparison was January 1, 2019–August 31, 2019, and the postimplementation period was January 1, 2020–August 31, 2020. All invasive procedures that required documentation in addition to a procedure note were included in the study. The primary outcome was the percentage of compliance with documentation requirements. ResultsDuring the pre- and postimplementation study periods, 486 and 405 charts with nonemergent procedures were identified, respectively. In the preimplementation period, 278 (57%) procedures were compliant with all documentation, vs. the postimplementation period, where 287 (71%) procedures were compliant (p < 0.001). ConclusionImplementing an invasive procedure documentation infographic and direct feedback improved overall documentation compliance for nonemergent invasive procedures.