Electronic Medical Record Documentation Research Articles

Documentation in the patient medical record was associated with improved adherence to Poisons Information Centres telephone advice

Context: There is little research examining clinician adherence to specialist toxicological phone advice. Efforts to improve adherence should be sought to optimise the management of poisoned patients. This study aimed to determine if contemporaneous documentation in the patient electronic medical record (EMR) improved adherence to Poisons Information Centre (PIC) advice.Methods: This was a prospective before and after observational study following the implementation of documented poisoning management advice by PIC staff into the patient’s EMR. Advice adherence was assessed following a review of the patient medical records and designated to complete adherence, minor discrepancies not affecting patient care, major discrepancies affecting patient care and non-adherence. The primary outcome was the proportion of satisfactory (complete adherence/minor discrepancies) adherence. Secondary outcomes included the accuracy of documented telephone advice by the treating clinician, the number of case recalls and episodes of sub-optimal management.Results: A total of 980 cases (347 in the pre-intervention phase and 633 in the post-intervention phase) were included in the study, of which 350 had PIC EMR documentation performed. Documented call advice by the treating clinician was absent in 41 of 347 cases (11.8%) cases and inaccurate in 42 of 306 cases (13.7%). Following PIC documentation, satisfactory adherence improved from 304/347(87.6%) to 333/350(95.1%)(difference 7.5% [95% CI 3.1% to 11.9%]), with suboptimal management decreasing from 48/347(13.8%) to 14/350(4%)(difference − 9.8% [95% CI −5.5% to −14.4%]). Recalls were similar in both periods. The median time to enter advice into the EMR was 26 min (IQR: 14–45 min). The main reason for not documenting advice was that the PIC staff member was working a solo shift with a prohibitively heavy workload.Discussion: EMRs enable PICs to supplement verbal advice with written documentation, offering an opportunity to improve communication and enable better handover of clinical information.Conclusion: Documentation of advice by PIC staff in the patient medical record was associated with improved advice adherence and reduced sub-optimal management.

No date for the PROM: the association between patient-reported health events and clinical coding in primary care

ObjectiveIt is unclear whether data from patient-reported outcome measures (PROMs) are captured and used by clinicians despite policy initiatives. We examined the extent to which fall risk and urinary incontinence (UI) reported on PROMS and provided to clinicians prior to a patient visit are subsequently captured in the electronic medical record (EMR). Additionally, we aimed to determine whether the use of PROMs and EMR documentation is higher for visits where PROM data was provided to clinicians.DesignWe conducted a cross-sectional patient-reported risk assessment survey and semi-structured interviews with clinicians to identify themes related to the use of PROMs.SettingFourteen primary care clinics in the US (eight intervention and six control clinics), between October 2013 and May 2015.ParticipantsPrimary care clinicians and older adult (≥66 years) patients completing a 46-item health risk assessment, including PROMs for fall risk and UI.InterventionRisk assessment results provided to the clinician or nurse practitioners prior to the clinic visit in intervention clinics; data was not provided in control clinics.Main outcome1) Agreement between ICD-9 codes of fall risk or UI in the EMR and patient-reports, and 2) clinician experience of PROMs use and impact on coding.ResultsA total of 505 older adult patients were included in the study, 176 at control clinics and 329 at intervention clinics. While patient reports of fall risk and UI were readily captured by PROMs, this information was only coded in the EMR between 3% – 14% of the time (poor Kappa agreement). Intervention clinics performed slightly better than control clinics. Clinician interviews (n = 16) revealed low use of PROMs data with multiple barriers cited including poor access to data, high quantity of data, interruption to workflow, and a lack of training on PROMs.ConclusionsCurrent strategies of providing PROMs data prior to clinic visits may not be an effective way of communicating important health information to busy clinicians; ultimately resulting in underuse. Better systems of presenting PROMs data, and clinician training on the importance of PROMs and their use, is needed.

Goals of care designations in advanced pancreatic cancer patients undergoing palliative chemotherapy.

683 Background: Discussion of goals of care (GoC) is a key part of quality care for patients with palliative cancer. Numerous studies have shown that documentation of GoC in this population remains low. In 2014, Alberta Health Services launched a health-system wide initiative to provide patients with physical copies of their GoC designation intended to be available at all health-system interactions. Here we describe rates of GoC documentation in the period surrounding this initiative. Methods: This is a retrospective cohort analysis of 240 patients with locally advanced or metastatic pancreatic cancer treated with palliative chemotherapy from 2012-2015 in Alberta, Canada. Data were obtained from outpatient electronic medical record documentation and the provincial cancer registry. Results: 63.8% (153/240) of patients had a documented GoC discussion, with 60.4% (145/240) receiving a specific GoC designation. 59.6% (143/240) of patients were referred to palliative care, with 32.5% (78/240) seen by palliative care physician. Of 334 individual GoC discussions documented, 38.6% (129/334) were by medical oncologists, 2.3% (10/334) were by radiation oncologists, 27.2% (91/334) were by palliative care, and 19.2% (64/334) were by other inpatient physicians during hospital admissions. At least 9.6% (32/334) referenced discussions that occurred prior to initial consultation with an oncology physician. Conclusions: The majority of pancreatic cancer patients undergoing palliative chemotherapy had a documented GoC designation during the study period. Providing patients with physical copies of their GoC designation may therefore represent a simple but effective means of increasing GoC documentation in the outpatient oncology setting.

Novel methodology to measure pre-procedure antimicrobial prophylaxis: integrating text searches with structured data from the Veterans Health Administration\u2019s electronic medical record

BackgroundAntimicrobial prophylaxis is an evidence-proven strategy for reducing procedure-related infections; however, measuring this key quality metric typically requires manual review, due to the way antimicrobial prophylaxis is documented in the electronic medical record (EMR). Our objective was to electronically measure compliance with antimicrobial prophylaxis using both structured and unstructured data from the Veterans Health Administration (VA) EMR. We developed this methodology for cardiac device implantation procedures.MethodsWith clinician input and review of clinical guidelines, we developed a list of antimicrobial names recommended for the prevention of cardiac device infection. We trained the algorithm using existing fiscal year (FY) 2008–15 data from the VA Clinical Assessment Reporting and Tracking-Electrophysiology (CART-EP), which contains manually determined information about antimicrobial prophylaxis. We merged CART-EP data with EMR data and programmed statistical software to flag an antimicrobial orders or drug fills from structured data fields in the EMR and hits on text string searches of antimicrobial names documented in clinician’s notes. We iteratively tested combinations of these data elements to optimize an algorithm to accurately classify antimicrobial use. The final algorithm was validated in a national cohort of VA cardiac device procedures from FY2016–2017. Discordant cases underwent expert manual review to identify reasons for algorithm misclassification.ResultsThe CART-EP dataset included 2102 procedures at 38 VA facilities with manually identified antimicrobial prophylaxis in 2056 cases (97.8%). The final algorithm combining structured EMR fields and text note search results correctly classified 2048 of the CART-EP cases (97.4%). In the validation sample, the algorithm measured compliance with antimicrobial prophylaxis in 16,606 of 18,903 cardiac device procedures (87.8%). Misclassification was due to EMR documentation issues, such as antimicrobial prophylaxis documented only in hand-written clinician notes in a format that cannot be electronically searched.ConclusionsWe developed a methodology with high accuracy to measure guideline concordant use of antimicrobial prophylaxis before cardiac device procedures using data fields present in modern EMRs. This method can replace manual review in quality measurement in the VA and other healthcare systems with EMRs; further, this method could be adapted to measure compliance in other procedural areas where antimicrobial prophylaxis is recommended.

The Case for Writing Critical Thinking Reports as a Teaching Strategy on Today's Hospital Wards.

I review some of the challenges in teaching medical students and housestaff on today’s hospital medicine wards, including increasingly limited time for dedicated teaching. Tapping into the extensive literature of “writing to learn” or “writing-across-the curriculum” in non-medical educational settings ranging from elementary school to college classes, I urge consideration of writing concise critical thinking reports (CTRs) by medical students and housestaff in response to questions raised during patient rounds as a means of enhancing their ward-based learning experience. Several potential reasons for writing CTRs are offered: (1) Nurtures curiosity; (2) Demands self-directed search for and encoding of new knowledge; (3) Emphasizes metacognition and conceptualization crucial to meaningful learning; (4) Provides opportunity for learners to teach and share newly-assimilated material with a broader web-based audience; (5) Encourages the concept of narrow but more in-depth learning related to a specific clinically relevant subject matter; (6) Nudges learners toward clear and succinct writing as an important general skill to develop in their everyday professional activities, including electronic medical record documentation; and (7) Reduces work-related burnout. Barriers to writing CTRs, including lack of general appreciation for explanatory writing as a potential teaching strategy in medical education and allowing sufficient time for medical students and housestaff to engage in this activity among other competing demands, are discussed. Writing CTRs is a potentially powerful pedagogical tool in ward-based learning that deserves consideration and formal evaluation by properly designed studies.

Pediatric Residency Obesity and Overweight Training Curricula: A Systematic Review.

Background. Pediatric obesity has become a significant public health concern. Pediatricians are the ideal group to help identify and treat this epidemic, but unfortunately, many pediatricians are not trained to discuss obesity with patients and their families. Standardized training initiatives for pediatric residents on prevention and/or management of obesity are needed to equip emerging pediatricians to combat the obesity epidemic. Objectives. This systematic literature review aims to examine the effectiveness of childhood obesity prevention/counseling resident training interventions. Methods. A comprehensive literature search was performed using preidentified search terms and limited to articles published prior to November 6, 2019. Articles were analyzed by 2 reviewers with a standardized evaluation tool. Results. A total of 698 articles were identified by the search. These were reduced to 111 articles after title review and 11 articles following abstract/full paper review. The 11 articles described 10 different obesity training interventions for residents. The articles varied in their size, length of training session, and study design. Despite these variations, all articles outlined positive outcomes, including an increase in physician confidence, positive changes in behavior, and/or improved electronic medical record documentation. Conclusions. With the continued increase in pediatric obesity, there is a need for practical, easy-to-implement, standardized trainings for pediatric residents on obesity prevention and treatment. More investigation needs to be done to look at long-term results of current interventions as well as other outcomes such as whether physicians are correctly identifying patients who are overweight or obese and whether there is improvement in patient follow-up.

Digital psychosocial assessment: An efficient and effective screening tool.

A large proportion of young people with chronic health conditions are surviving into adulthood. They face the same challenges as their healthy peers and are at increased risk of mental health problems. Psychosocial assessment is a crucial aspect of clinical care. Interviews using the internationally used and accepted HEEADSSS (home environment, education/employment, eating, peer-related activities, drugs, sexuality, suicide/depression, and safety) framework require trained clinicians, rapid interpersonal engagement, time and manual documentation. HEEADSSS-derived digital self-report surveys can be initiated by non-trained staff. This study compares the utility and information recorded using both methods. A retrospective analysis comparing documentation from HEEADSSS guided face-to-face interview and a digital survey tool was conducted using 146 records collected by the Trapeze transition service across the two locations of the Sydney Children's Hospital Network (NSW, Australia) between 2013 and 2016. A panel of four experts used an iterative process to identify 29 data verification points, falling into seven categories. Wilcoxon signed-rank tests were used to compare category scores. The digital survey took an average of 15 min and showed a significantly higher rate of disclosure across all psychosocial categories, particularly in the sensitive areas of emotions, drug use, sex and safety, compared to electronic medical record documentation of interview. Digital survey provided a time-efficient psychosocial screening tool that was self-administered, able to be introduced by non-trained staff, had a consistent record of responses, and elicited a substantially higher disclosure rate for important areas of strength and risk that may otherwise be avoided or not recorded.

Frequency of preconception education for teenage patients with diabetes attending an academic Pediatric Endocrinology Clinic

Purpose: Diabetes mellitus (DM) in pregnancy produces adverse outcomes with significant human and economic costs. Potential lifetime cost savings of preventative preconception counseling for women with diabetes may reach $4.3 billion (U.S.). Preconception education has been shown in prior research to improve knowledge of reproductive risks in an adolescent diabetic population and to improve future health outcomes. This study assessed the current extent of preconception DM-related reproductive risk education at a tertiary academic medical center to better inform the opportunity for a systematic quality improvement intervention. Methods: We reviewed the electronic medical records (EMR) of females (N=70), ages 16-19, seen in the Pediatric Endocrinology clinic (2013-2016) and diagnosed with type 1 DM, type 2 DM, or insulin resistance. Any reproductive risks education documentation by providers, nursing or educators within Pediatric Endocrinology, or within consults to Nutrition or Obstetrics and Gynecology was reviewed and characterized. Results: According to EMR documentation, patient education for nonreproductive medical needs and complications of DM were consistently present in this population: 96% of patients received general diabetes education with at least 4/8 components. However, documented education regarding DM reproductive risks occurred for only 18% of the same patients while contraceptive use discussion occurred for 20%. Conclusion: The potential benefits of preconception education may include achieving recommended glucose control preceding and during pregnancy with fewer downstream maternal and fetal adverse outcomes. Although limited by the single site, retrospective design and the unknown rate of reproductive education documentation failure, our findings reveal a performance gap of potential downstream medical significance. Recognizing this deficiency provides an opportunity for a population-based intervention to create improved health outcomes.

Documentation of medical marijuana use in cancer patients.

Medical marijuana is often used as adjuvant therapy in cancer patients for symptom management, although limited evidence-based studies evaluating its efficacy or safety exist. Similar to over-the-counter medications, supplements, or herbal products, documentation of medical marijuana is important to monitor efficacy, potential adverse effects, or interactions. The objective of this quality improvement study was to improve the consistency of medical marijuana documentation in cancer patients by assessing current practices; educating healthcare team members about the importance of documentation and newly established documentation process; and evaluating the new documentation process. This three-part quality improvement study was approved by the Institutional Review Board. In part I, a voluntary survey was sent via email to Cancer Center healthcare personnel to assess the current documentation process of medical marijuana. In part II, a best practice process for documenting medical marijuana in the electronic medical record was established. Medical marijuana was to be listed as a historical medication in the medication list. In-person and electronic education sessions were offered to Cancer Center clinical staff. The education emphasized the importance of documenting medical marijuana use and provided a detailed process for electronic medical record documentation. A pre- and post-test to assess understanding was also included. Part III was a retrospective chart review to evaluate documentation practices of certified medical marijuana users in the Cancer Center. Patients included in the study were greater than 18 years old and certified for medical marijuana use on or after 1 January 2018. Department of Corrections patients were excluded. Descriptive statistics were used for data analysis. The survey results in part I demonstrated a lack of consistency in the documentation of medical marijuana in the Cancer Center. The pre- and post-test scores measured in part II showed a significant improvement in understanding after education was provided. The average pre-test score was a 61 and post-test score was 88, indicating an average increase of 27 points. A larger increase in test scores was observed in those attending the in-person education than the online sessions (p < 0.002). The results of the retrospective chart review in part III revealed 56 patients who met inclusion criteria, but only 39 patients were alive and evaluated at the time of the retrospective chart review. Of the 39 patients, 22 never completed the patient registration process and therefore, would never have been able to obtain medical marijuana. Seven patients had medical marijuana properly documented in their medication list and 10 patients were missing documentation in the medication list, showing room for improvement in documentation practices. This quality improvement study led to the implementation of medical marijuana documentation in the medication list. Education increased healthcare team members understanding of medical marijuana utilization and the importance of documentation.

How Nurse Experience Influences the Patterns of Electronic Medical Record Documentation in an Intensive Care Unit

The primary objective of this study is to explore how nurse experience influences the patterns of documenting in electronic medical records (EMR) in an intensive care unit (ICU). To understand the time and work patterns related to EMR documentation, the real-time measurement system data was used. This log data is a representation of actions taken by ICU nurses during EMR documentation. To analyze the ICU nurse’s workflow related to EMR documentation, a hierarchical task analysis (HTA) was conducted. Multiple HTA charts were used to identify different patterns of EMR documentation between more experienced nurses and less experienced nurses. The results revealed that the nurse’s experience had significant impacts on the frequency of updating the assessment result page and reviewing clinical results in EMR. The findings from this study will contribute to revealing unknown usability problems of EMR documentation process.

1021. Accuracy of Provider-Selected Antibiotic Indications at Point of Order Entry Compared with Electronic Health Record Documentation

BackgroundThe Centers for Medicaid and Medicare Services (CMS) state that hospital antimicrobial stewardship (AMS) policies require indications be documented for all orders. This may be included in the electronic medical record (EMR) or during order entry per CMS. Reliance solely on EMR documentation may be inconsistent or absent at times. In an effort to optimize compliance to this new measure and improve antibiotic use tracking, the University of Colorado AMS committee implemented required indications for all systemic antimicrobial orders. To follow up on this intervention we sought to determine the accuracy of ordered indication based on EMR documentation.MethodsRetrospective review of antibiotics ordered between May 2, 2017 and December 1, 2017 among hospitalized patients aged 18–89 years. The primary objective was the accuracy of provider-selected indications (PSI) compared with EMR documented-clinical indication (DCI). Secondary objectives included accuracy comparison between check-box and free-text PSI format, and adherence to institutional antibiotic use guidelines. Differences between proportions of antibiotic orders with certain variables were assessed with Pearson’s chi-square and Fisher’s exact as appropriate.ResultsA total of 304 patients were evaluated with a median age of 56 years, 49% male, and 31% identified as immunocompromised. Check-box was most utilized in 81%, with 93% having a single indication selected. Most orders were classified as empiric (63%), followed by prophylaxis (23%) and definitive (15%). Frequent indications chosen were pneumonia (17%), bacteremia (13%), skin and soft tissue (10%), urinary tract infection (9%), and intra-abdominal infections (5%). Accuracy by PSI/DCI match was 78%, which was not different by a method of indication entry. Only indication type (P = 0.023) and care team specialty (P = 0.009) were shown to significantly impact accuracy. Nonadherence to institutional guidelines was 19%.ConclusionAntibiotic indications on order entry are an effective strategy to improve documentation and meet compliance around new CMS standards. Ordering by surgical services and prophylactic indications had lower PSI/DCI match, mostly resulting from absent EMR indication documentation.Disclosures All authors: No reported disclosures.

23.2 WORKING WITH MEDICAL SCRIBES, MEDICAL ASSISTANTS, AND REGISTERED NURSES TO IMPROVE OUTPATIENT CLINIC WORKFLOW AND SUPPORT PHYSICIAN WELLNESS

A lecture presentation will be used to present issues related to physician burnout, specific to electronic medical record (EMR) documentation burden, and inefficiencies in clinical workflow. Since the implementation of the EMR, physicians spend more time on documentation and EMR-prompted tasks. The EMR has contributed to decreased efficiency during the patient visit and lengthier work hours to complete required documentation, both of which contribute to physician work dissatisfaction and burnout.

Resident Mental Health: Time for Action.

Resident Mental Health: Time for Action.

Addressing Diabetes in Primary Care: Hybrid Effectiveness-Implementation Study of Lifestyle Redesign® Occupational Therapy.

Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy's feasibility and efficacy in primary care settings. To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)-occupational therapy (LR-OT) diabetes management intervention in a primary care clinic. Patients were randomized to be offered LR-OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods. Safety-net primary care clinic. Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18-75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%. Eight 1-hr individual sessions of LR-OT focused on diabetes management. Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR-OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations. Seventy-three patients were offered LR-OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation. LR-OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care. This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy's effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

A Prediction Model for Identifying Type 2 Diabetics at Highest Risk of Cardiorenal Outcomes

Background Type 2 diabetes mellitus (T2DM) affects around 10% of the US adult population and associates with high levels of cardiovascular (CV) and renal morbidity and mortality. Recent randomized clinical trials in T2DM have shown cardiorenal benefits with novel antidiabetic therapies. Real world utilization of these therapies may be maximally cost-effective when targeted to those at highest risk of cardiorenal outcomes. Accordingly, this study created a risk prediction model for a composite cardiorenal endpoint of CV death, hospitalization for heart failure (HHF), and end stage renal disease (ESRD) in T2DM patients and proposes a quantitative risk threshold for labeling patients as being at high risk of this outcome. Methods This retrospective cohort study included patients with pre-existing or newly diagnosed T2DM drawn from the electronic medical record (EMR) of a single, large integrated health care system. Candidate predictors for prediction model development were determined from EMR documentation in the two years prior to a baseline office visit. A time-to-first-event variable was created for the composite endpoint of CV death, HHF, and ESRD, and significant predictors determined using Cox regression. “High risk” patients were defined as the 10% highest risk patients according to prediction model output. Results Among 57,646 T2DM patients, 8505 (15%) experienced an event over a mean follow-up of 6.9 years. CV death was the most frequent outcome (53% of first events), followed by HHF (25%) and ESRD (22%). The strongest predictors of the composite outcome were age, blood urea nitrogen, coronary artery disease, HF, and atrial fibrillation. The final proposed 19-predictor model had a c-statistic of 0.792. The 10% highest risk patients (“high risk”) according to prediction model variables had estimated event rates >5%, >15%, and >30% at 1, 3, and 5 years after the baseline date. Conclusions T2DM patients have a high rate of CV and renal outcomes, and recent clinical trial evidence shows novel antidiabetic therapies reduce these outcomes. Patients at highest risk for these outcomes are expected to receive the greatest event rate reduction from these novel therapies.

EMR documentation of genetics evaluations in patients with ovarian cancer.

e13156 Background: Genetic testing for hereditary cancer predisposition has become increasingly complex yet impactful. Provider knowledge of test results influences risk management, implications for family members, and therapeutics. Currently, it’s unknown if genetic test (GT) results are appropriately recorded and accessible within the electronic medical record (EMR). Methods: We conducted a single-institution retrospective chart review to examine clinical diagnoses, family history of cancer, genetics referrals, and genetics services received at University of Pennsylvania’s Cancer Risk Evaluation Program (CREP) or elsewhere. The study cohort included new and prevalent cases of ovarian cancer (OC) seen by either a gynecologic or medical oncologist at the University of Pennsylvania in 2016. Analyses were conducted using SAS 9.4. Results: 667 women (83% white, 9% black, 4% Asian; mean age 61) with OC were included. 58% had a documented family history of breast, ovarian, prostate or pancreas cancer. 48% had documentation of referral to genetic testing and an additional 26% had documentation of testing outside of CREP. 26% had no documentation of referral or testing. Of those referred to CREP, 75% had genetic testing: in total 62% of the cohort had documented testing. 94% of those tested had a result documented in a provider note, and 64% had a scanned testing report uploaded into the EMR, including 74.3% of those tested through CREP and 25.7% of those tested outside. Among the 118 pathogenic mutations, 70% were documented on the EMR “problem list.” Conclusions: In this study, most, though not all, OC patients had documentation of a GT referral or testing in the EMR. Although GT results were routinely included in progress notes, these reports were less commonly scanned into the EMR (particularly for those tested outside Penn) or included in the EMR “problem list” which is both searchable and immediately visible. Capturing genetic data in a uniform and easily accessible manner within the EMR is necessary to maximize clinical utility of this information and should be a focus for EMR module development.

Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention

ContextOptimal advance care planning allows patients to articulate their values as a touchstone for medical decision making. Ideally, this occurs when patients are clinically stable, and with opportunities for iteration as the clinical situation unfolds. ObjectivesTesting feasibility and acceptability in busy outpatient oncology clinics of a novel program of systematic, oncology nurse-led values discussions with all new cancer patients. MethodsWithin an institutional initiative integrating primary and specialist palliative care from diagnosis for all cancer patients, oncology nurses were trained to use specific questions and an empathic communication framework to discuss health-related values during outpatient clinic visits. Nurses summarized discussions on a template for patient verification, oncologist review, and electronic medical record documentation. Summaries were reviewed with the patient at least quarterly. Feasibility and acceptability were evaluated in three clinics for patients with hematologic or gastrointestinal malignancies. ResultsOncology nurses conducted 177 total discussions with 67 newly diagnosed cancer patients (17 with hematologic and 50 with gastrointestinal malignancies) over two years. No patient declined participation. Discussions averaged eight minutes, and all patients verified values summaries. Clinic patient volume was maintained. Of 31 patients surveyed, 30 (97%) reported feeling comfortable with the process, considered it helpful, and would recommend it to others. Clinicians strongly endorsed the values discussion process. ConclusionNurse-led discussions of patient values soon after diagnosis are feasible and acceptable in busy oncology clinics. Further research will evaluate the impact of this novel approach on additional patient-oriented outcomes after broader dissemination of this initiative throughout our institution.

Nurses' Perception of the Impact of Electronic Documentation on the Nurse-Patient Relationship

While there are many benefits of electronic medical record documentation, the presence of a computer may adversely affect provider-patient interaction. The purpose of this project was to examine staff nurses' perception of the impact of electronic documentation in the presence of the patient on the nurse-patient relationship. A survey was administered to 276 staff nurses, and open-ended interviews were conducted with 11 novice and 20 expert nurses. Nurses identified benefits and challenges to electronic medical record documentation as well as strategies used to maintain therapeutic relationships and communication. Numerous nurses commented that documenting with their back to the patient had a negative impact on the nurse-patient relationship and communication. Both novice and expert nurses identified strategies that they used to ensure they were "maintaining the connection" to patients during electronic medical record documentation.

Emergency Medicine Residents on Electronic Medical Records: Perspectives and Advice.

Given the near-universal implementation of electronic medical records (EMRs) in emergency departments (EDs), emergency medicine (EM) residents spend significant time interfacing with EMRs without any established national curriculum to learn best practices. While EMRs have the potential to increase physician efficiency and improve the quality of documentation, they have also been cited as a factor in physician burnout. Understanding the target audience of the EMR, knowing what and when to chart, and practicing time-saving strategies can streamline the process of charting. We review the literature on the current state of EMR documentation by residents and provide recommendations for best practices.

Abstract WP415: Electronic Stroke Care Pathway Significantly Increases Quality Improvement Metric Documentation and Patient Education

Introduction: Stroke accounts for 1 in 20 deaths in the US, and increasing stroke healthcare costs are projected to rise to $185 billion yearly by 2030. Care Pathways use standardized electronic medical record (EMR) documentation, order sets, and clinical decision support to streamline institution-wide care delivery and have been shown to improve outcomes. We hypothesize that the Acute Ischemic Stroke (AIS) Care Pathway increases EMR documentation of quality improvement metrics. Methods: The AIS Care Pathway was implemented starting in 11/2015. It streamlines workflow by providing users with EMR documentation tools, order sets, and clinical aids. We compared the documentation of quality improvement metrics in patients on and off the Care Path, including stroke education and documentation of last known well (LKW), NIH stroke scale (NIHSS), and modified Rankin Scale (mRS). Results: In 2017, 2,728 patients were diagnosed with AIS; 77% of patients were placed On Care Path, and 23% were Not On Care Path. Documentation of LKW (81% vs 29%, p&lt;0.01), admission NIHSS (100% vs 62%, p&lt;0.01), admission mRS (99% vs 60%, p&lt;0.01), discharge NIHSS (75% vs 46%, p&lt;0.01), and discharge mRS (78% vs 49%, p&lt;0.01) were significantly higher for patients On Care Path compared to those Not On Care Path (Table 1). Likewise, a higher proportion of patients On Care Path received nursing stroke education (74% vs 48%, p&lt;0.01). Conclusions: AIS Care Pathway significantly increases documentation of quality improvement metrics and education related to stroke care. These are electronically abstracted data that can eliminate the need for manual abstraction.