Chart Notes Research Articles

Toward Efficient, Sustainable, and Scalable Methods of Treatment Characterization: An Investigation of Coding Clinical Practice from Chart Notes.

Chart notes provide a low-cost data source that could help characterize what occurs in treatment with sufficient precision to improve management of care. This study assessed the interrater reliability of treatment content coded from chart notes and evaluated its concordance with content coded from transcribed treatment sessions. Fifty randomly selected and digitally recorded treatment events were transcribed and coded for practice content. Independent coders then applied the same code system to chart notes for these same treatment events. We measured reliability and concordance of practice occurrence and extensiveness at two levels of specificity: practices (full procedures) and steps (subcomponents of those procedures). For chart notes, practices had moderate interrater reliability (M k = 0.50, MICC = 0.56) and steps had moderate (M ICC = 0.74) to substantial interrater reliability (M k = 0.78). On average, 2.54 practices and 5.64 steps were coded per chart note and 4.53 practices and 13.10 steps per transcript. Across sources, ratings for 64% of practices and 41% of steps correlated significantly, with those with significant correlations generally demonstrating moderate concordance (practice M r = 0.48; step M r = 0.47). Forty one percent of practices and 34% of steps from transcripts were also identified in the corresponding chart notes. Chart notes provide an accessible data source for evaluating treatment content, with different levels of specificity posing tradeoffs for validity and reliability, which in turn may have implications for chart note interfaces, training, and new metrics to support accurate, reliable, and efficient measurement of clinical practice.

Interprofessional Art Rounds

Art Rounds is an interprofessional workshop that uses art to develop nursing and medical students' observation skills and empathy. The workshop's joint emphasis on interprofessional education (IPE) and visual thinking strategies (VTS) is intended to improve patient outcomes, strengthen interprofessional collaboration, and maintain a climate of mutual respect and shared values. Interprofessional teams of 4 to 5 students practice faculty-guided VTS on artworks. Students then apply VTS and IPE competencies in observing, interviewing, and assessing evidence during 2 encounters with standardized patients (SPs). Students also write a chart note that includes differential diagnoses with supportive evidence for each of the 2 SPs. Art Rounds focuses on students' observation of details and interpretation of images and SPs' physical appearance; evaluation strategies include grading rubrics for the chart notes and a student-completed evaluation survey.

915. Implementation of Face-to-Face Antimicrobial Stewardship Rounding at a Veterans Affairs Hospital

Abstract Background The Veterans Affairs Central California Healthcare System (VACCHCS) antimicrobial stewardship program primarily utilizes prospective audit-feedback. Initially, antimicrobial recommendations were communicated to medicine and surgery teams exclusively through chart notes. Beginning September 2021, a new process was initiated whereby all antibiotic recommendations were communicated to care teams during daily face-to-face rounds. This pre-post cohort study is an assessment of the changes in antimicrobial use, inpatient mortality and 30-day readmissions that occurred with the intervention. Methods Both pre- and post- intervention, all admitted patients with active antibiotic orders were reviewed for antibiotic optimization by an ID team and a chart note was written to document recommendations. Post-intervention, recommendations were communicated via daily face-to-face rounds with medicine and surgery services. Total antibiotic use was collected from the National Healthcare Safety Network’s Antimicrobial Use and Resistance (NHSN-AUR) Module as antibiotic days-of-therapy per 1000 patient days (DOT/1000). Monthly in-hospital mortality and 30-day readmission data were collected from the VA’s Corporate Data Warehouse. Median monthly amounts of each measure were compared pre- and post-intervention. Antibiotic use was compared monthly for 2 years prior and 3 months post intervention, whereas mortality and readmission outcomes included 2 years prior and 6 months post-intervention. Results Pre and post-intervention median monthly antibiotic use was 728 and 741 DOT/1000, respectively. Median monthly mortality was seven deaths pre-intervention and six post-intervention. Median monthly 30-day readmissions were 48 pre-intervention and 36 post-intervention. Conclusion Total antibiotic use slightly increased after the intervention. Further post-intervention observation is needed in order to better characterize impact on antimicrobial use. Monthly in-hospital mortality and 30-day readmission data were decreasing prior to our intervention and continued to decrease post-intervention. Disclosures All Authors: No reported disclosures.

No Longer Beholden – Moving On from Elaborate Chart Notes

Despite recent changes in Medicare billing documentation guidelines, physician chart notes remain far lengthier and more detailed than is required. This is worrisome, as documentation burden is a major contributor to physician burnout. Elements of medical culture which have contributed to the elaborate chart note standard may be used to transform notes, reduce charting burden and improve physician well-being.

An Analysis of Chaplains' Narrative Chart Notes Describing Spiritual Care Visits with Gender Affirmation Surgical Patients.

The benefit of spiritual care for patients is well described, but little is known about the role of spiritual care in transgender and nonbinary patients recovering from gender affirming surgeries (GASs). A single-center retrospective chart review was performed on patients who underwent GAS in 2017. Demographic information, surgery type, and chaplains' narrative notes were examined. A total of 145 chaplain visits were identified in 103 inpatient stays among 98 patients at the Mount Sinai Center for Transgender Medicine and Surgery in New York. Analysis was performed on narrative notes authored by a single chaplain, which included 132 visits among 78 transfeminine and 11 transmasculine patients. Fifty-four patients (61%) expressed gratitude for the chaplain visit and/or hospital experience overall. Seven patients (8%) described movement between religious denominations over the course of their lives, and 7 (8%) described supportive belief systems. Fifty-seven patients (64%) had a family member or friend present during the perioperative process, 13 (15%) described support systems, and 9 (10%) described supportive practices, activities, and/or coping methods. Twenty-one patients (24%) expressed concerns about current symptoms or the recovery process, and 32 (36%) received a prayer or blessing from the chaplain. Fifty-two patients (58%) consented to a follow-up call. Almost 50% of patients expressed gratitude for the chaplain's visit and more than half consented to a follow-up call from the chaplain, suggesting a chaplain can provide a welcome layer of support to postoperative GAS patients. The authors recommend integrating spiritual care into perioperative care.

When patients and surgeons disagree about surgical outcome: investigating patient factors and chart note communication.

ObjectiveEffective physician-patient communication is a critical component of a clinical practice and in order to achieve optimal patient outcomes. We aimed to investigate indirect effects of physician-patient communication by examining the relationship between a physician-patient mismatch in perceived outcomes and content in the medical record’s clinical note. We compared patient records whose perceived subjective assessment of surgery outcomes agreed or disagreed with the surgeon's perception of that outcome (Subjective Disagreement).MethodsThis study included 172 spine surgery patients at a teaching hospital. Patient-reported outcomes included the Oswestry Disability Index; the Short-Form 36; and a Visual Analogue Scale items for leg and back pain. We content-analyzed the clinical note in the medical record, and used logistic regression to evaluate predictors of Subjective Disagreement (n = 41 disagreed vs. 131 agreed).ResultsPatient and surgeon agreed in 76 % of cases and disagreed in 24 % of cases. Patients who assessed their outcome worse than their surgeons tended to be less educated and involved in litigation. They also tended to report worsened mental health and leg pain. Content analysis revealed group differences in surgeon communication patterns in the chart notes related to how symptom change was emphasized, how follow-up was described, and a specific word reference. Specifically, disagreement was predicted by using “much” to emphasize the findings and noting long-term prognosis. Agreement was predicted by use of positive emphasis terms, having an “as-needed” follow-up plan, and using “happy” in the chart note.ConclusionThe nature of measuring outcomes of surgery is based on patient perception. In surgeon-patient perspective mismatches, patient factors may serve as barriers to improvement. Worsened change on patient-reported mental health may be an independent factor which colors the patient’s general perceptions. This aspect of treatment may be missed by the spine surgeon. Chart note communication styles reflect the subjective disagreement. Investigating and/ or treating mental health deterioration may be valuable in resolving this mismatch and for overall outcome.Electronic supplementary materialThe online version of this article (doi:10.1186/s12955-015-0343-0) contains supplementary material, which is available to authorized users.

Indicators of Pediatric Malnutrition in a Tertiary Care Hospital.

This study was conducted to determine the prevalence of malnutrition at a Canadian children's hospital based on medical records and to identify gaps in current practices and rates/reasons for dietitian consult. A retrospective chart audit of patients admitted during a winter season was completed. Patients with length of stay <4 days were excluded, as were those with fluid retention diseases. Outcome variables included anthropometrics, diet order, rates and reasons for dietitian consult, and biochemical data. Of the 83 charts reviewed (mean ± SD age 7.3 ± 5.6 years of age), weights were recorded less frequently than recommended (45% of patients ≤2 years of age and 85% of patients >2 years of age met or exceeded recommendations). Twenty-nine (36%) patients were identified at potential increased nutrition risk for overweight, 10 (12%) for underweight, and 31 (38%) patients had nutrition-related chart notes. Only 23 patients (28%) received a dietitian consult and, of those, 21 had a nutrition related chart note. Consultation occurred an average 5.4 ± 4.96 days after admission. These data emphasize the need for development of standardized screening and assessment tools to better identify pediatric patients at risk for malnutrition and to improve access to optimal nutrition care.

Practical Guidance for Charting Ethics Consultations

It is generally accepted that appropriate documentation of activities and recommendations of ethics consultants in patients' medical records is critical. Despite this acceptance, the bioethics literature is largely devoid of guidance on key elements of an ethics chart note, the degree of specificity that it should contain, and its stylistic tenor. We aim to provide guidance for a variety of persons engaged in clinical ethics consultation: new and seasoned ethics committee members who are new to ethics consultation, students and trainees in clinical ethics, and those who have significant experience with ethics consultation so that they can reflect on their practice. Toward the goal of promoting quality charting practices in ethics consultations, we propose recommendations on a broad array of questions concerning clinical ethics consultation chart notes, including whether and when to write a chart note, and practical considerations for the tenor, purpose, and content of a chart note. Our broader aim is to promote discussion about good charting practices in clinical ethics, with the hope of contributing to clear standards of excellence in clinical ethics consultation.

Quantifying headache symptoms and other headache features from chart notes.

To describe a method for quantifying headache symptoms/features in family practice charts for patients diagnosed with headache NOS (not otherwise specified, ICD-9: 784) and to determine the share of NOS headache diagnoses with clinical data strongly suggestive of migraine or probable migraine headache. Headache is one of the most common pain symptoms that brings patients to a family physician. However, the majority of headache sufferers do not receive a specific headache diagnosis when they visit physicians. We examined the chart notes of 454 patients exclusively diagnosed with one or more ICD-9 coded headache NOS diagnoses from July 1, 1995 through December 31, 1999 at a large suburban, university-affiliated practice. We developed a template containing 20 headache items combining International Headache Society diagnostic criteria and additional headache symptoms/features, and decision rules for coding symptoms/features and collected data from patient charts. We then developed decision rules and reclassified NOS headaches into categories strongly suggestive of migraine, probable migraine headache, or other diagnosis. Our main outcome measure is the consistency in the application of decision rules and diagnostic criteria. With this method we estimate 3 in 10 (29%) headache NOS patients may have had migraine (8%) or probable migraine headache (21%). Reclassified migraine visits averaged 6.5 migraine symptoms and reclassified probable migraine headache visits 4.7 migraine symptoms. Logistic regression analysis supports the consistency of diagnostic criteria for classifying headache based on coded symptoms/features--our model correctly predicted 96% of visits. Evidence of physical examination was recorded at 75% of visits suggesting that physician attention is focused on elimination of secondary headache. We think the use of our rigorous procedures reveals that a substantial amount of migraine and probable migraine headache may be missed in everyday practice. We hope our findings will provide a basis for the development of diagnostic methods more closely suited to the needs of nonspecialists, and contribute to a better standard of care for headache patients seen in primary care practice. Finally, we are hopeful that other researchers will consider using our template and guideline procedures in their efforts to identify diagnostic patterns and study headache and other health problems.

Superior student chart notes challenge Medicare documentation policies.

Superior student chart notes challenge Medicare documentation policies.

Quality of pharmacists' documentations in patients' medical records.

Training pharmacists to appropriately document patient-specific problems and recommendations in patients' medical records and subsequent monitoring of pharmacist-written documentation are described. The medical staff of a tertiary care teaching hospital recommended that pharmacists be allowed to write in the permanent portion of patients' medical records. A six-month pilot program was approved to train pharmacists in writing chart notes. Notes would be assessed according to the following criteria: necessity (i.e., a chart note was the appropriate means of communication), clarity, legibility, completeness, correct format, and lack of judgmental language. Initial training was by physicians from the pharmacy and therapeutics committee, with more extensive training by a committee composed of clinical and administrative pharmacists. After training ended, each pharmacist's first few notes were reviewed by a member of the pharmacy committee. The quality of pharmacist-written notes is reviewed quarterly. The first quarterly evaluation and another review 1 1/2 years later showed that all pharmacist notes met all of the established criteria. A multidisciplinary approach was effective in training pharmacists to document interventions appropriately in patients' permanent records. Ongoing monitoring ensures the continuing quality of such documentation.

Improving Communication Between Physicians and Dietitians:: Results of Physician Survey on Charting Methods

Hospital chart notes are a major route of communication between physicians and dietitians. Too often, however, there is a discrepancy between what dietitians provide in their notes and what physicians actually require. Lengthy notes with redundant information may result in the failure of recommendations to be implemented. To assess the charting methods at our institution, we designed a survey to directly ask physicians what they expect and prefer from the dietitians’ chart notes. Surveys were distributed to 135 physicians in various specialties throughout the medical center; 112 were returned (83%). Among the results, 47% of the respondents felt that chart notes were too long, and, of these, 93% said that this hindered them from reading the notes more often. Physicians identified recommendations (95%), estimated nutritional needs (61%), and nutritional assessment (60%) as the most helpful parts of the notes. Subjective comments (49%) and lists of laboratory values/medications (44%) were parts that respondents did not find useful and felt could be omitted. The majority of physicians (71%) preferred to be notified of dietitians’ recommendations through the chart note. These results will be used in our institution to restructure the nutrition information and recommendations provided to physicians. In this era of outcome-based health care, it is essential that dietitians continually take steps to increase the likelihood that recommendations are carried out and that patients ultimately benefit from the intervention.

Reviews and Notes: Medical Software: Dr. Welford's Chart Notes Program

Reviews and Notes: Medical Software: Dr. Welford's Chart Notes Program

Dr Welford's Chart Notes

ABSTRACT Dr Welford has succeeded in designing a workhorse program for the medical office. It was written by a practicing internist for his personal use and is primarily intended for use by physicians, residents, and medical students. It is not just another word processing program.Dr Welford's Chart Notes is an extensively integrated clinical information management program that includes such features as a drug interaction knowledge base, an ICDM code book, and a database manager for patient allergies, medications, and diagnoses. It also has an artificial intelligence that reads each note as it is being entered, automatically updates the patient's lists of allergies, medications, and diagnoses, and will simultaneously check for drug reactions or interactions and proper dosages whenever the physician starts or stops a patient's medication. Not only will a boxed warning appear on the screen, but the warning is also referenced should the user wish more information on the

Chart and Brief Notes of a Case of Cavernous Sinus Thrombosis following Left Tonsillitis in a Boy, Aged 10; Fatal Termination in Eighteen Days

Chart and Brief Notes of a Case of Cavernous Sinus Thrombosis following Left Tonsillitis in a Boy, Aged 10; Fatal Termination in Eighteen Days