Physician Documentation Research Articles

Developing a standardized EMR workflow for medical students and preceptors

ObjectivesThe electronic medical record (EMR) is an integral component of clinical encounters. However, there is no standardized curriculum for EMR education in medical school. This study aimed to create a standardized EMR workflow model for medical students in clinic. It was hypothesized that this workflow would be effectively implemented and increase physician productivity. MethodsAn outpatient clinic workflow model was created to integrate students into clinical visits as active participants in EMR documentation. 240 third and fourth-year medical students on their Neurology clerkship at a U.S. medical institution and 34 outpatient neurologists were trained on the workflow (student EMR integration training; SEIT). A total of 733 Neurology outpatient clinic days were analyzed (473 pre-SEIT and 251 post-SEIT). Productivity metrics included average lag time, average Relative Value Units (RVUs) per day, and average invoices per day. ResultsThere was a statistically significant difference in documentation time, with a pre-SEIT lag time of 14.7 days (SD 13.1 days, 95% CI 9.4–20.0) compared to 10.3 days post-SEIT (SD 10.2 days, 95% CI 6.2–14.5; p-value = 0.001). The average RVUs per day were 18.5 pre-SEIT (SD 7.8, 95% CI 15.4–21.7) and 17.8 post-SEIT (SD 8.0, 95% CI 14.6–21.0; p-value = 0.7). The average invoices per day were 7.5 pre-SEIT (SD 2.6, 95% CI 6.5–8.6) and 7.3 post-SEIT (SD 3.0, 95% CI 6.1–8.5; p-value = 0.5). ConclusionsThe workflow model utilizes medical student EMR documentation in the clinical note and decreases physician documentation time.

I had not time to make it shorter: an exploratory analysis of how physicians reduce note length and time in notes.

We analyze observed reductions in physician note length and documentation time, 2 contributors to electronic health record (EHR) burden and burnout. We used EHR metadata from January to May, 2021 for 130079 ambulatory physician Epic users. We identified cohorts of physicians who decreased note length and/or documentation time and analyzed changes in their note composition. 37857 physicians decreased either note length (n = 15647), time in notes (n = 15417), or both (n = 6793). Note length decreases were primarily attributable to reductions in copy/paste text (average relative change of -18.9%) and templated text (-17.2%). Note time decreases were primarily attributable to reductions in manual text (-27.3%) and increases in note content from other care team members (+21.1%). Organizations must consider priorities and tradeoffs in the distinct approaches needed to address different contributors to EHR burden. Future research should explore scalable burden-reduction initiatives responsive to both note bloat and documentation time.

Neurologic outcomes of carotid and other emergent interventions for ischemic stroke over 6years with dataset enhanced by machine learning.

The current mainstays of ischemic stroke treatment include the use of thrombolysis (tissue plasminogen activator [tPA]), urgent carotid endarterectomy (uCEA) or urgent carotid artery stenting (uCAS), and mechanical endovascular reperfusion/thrombectomy (MER). Scarce data describe the presenting stroke severity and neurologic outcomes for these acute ischemic stroke interventions, alone or in combination. The authors hypothesize that patients undergoing carotid interventions experience better functional neurologic outcomes than other stroke interventions. A comprehensive stroke center dataset was combined with data for stroke-related procedures, comorbidities, complications, and physician documentation collected from electronic medical record data. A total of 10,975 patient encounter records from January 1, 2015, through July 31, 2021, were retrieved. The presenting stroke severity was determined by vascular/stroke neurologists using the National Institutes of Health Stroke Scale (NIHSS). Functional neurologic outcomes were reported using the modified Rankin scale (mRS) score, which quantifies the degree of neurologic disability. Because mRS values were only available for 3627 encounters in the original dataset, the authors developed a machine learning algorithm to analyze physician documentation and assign an mRS value. After the exclusion and machine learning analysis, a total of 5170 patient encounters were included for statistical analysis. Statistical analyses included the χ2 test, one-way analysis of variance and logistic regression on 30-day complications, stroke severity, and neurologic outcomes. Patients were divided into five cohorts: (1) uCEA or uCAS (n= 189), (2) tPA alone (n= 1053), (3) MER alone (n= 418), (4) tPA+ MER (n= 199), and (5) no intervention (n= 3311). Patients undergoing uCEA/uCAS were significantly more likely to be male, smokers, and have a history of peripheral arterial disease compared with other stroke cohorts. The length of stay was shortest for patients who only received tPA or no intervention (6days), followed by uCEA/uCAS (7.2days), MER (10.2days), and tPA+ MER (8.8days) cohorts (P< .001). The 30-day mortality was highest in the MER cohort (12.2%) and lowest in the uCEA/uCAS cohort (2.6%). The uCEA/uCAS cohort compared with other cohorts had the lowest presenting stroke severity (NIHSS 4.9 vs NIHSS 6.9-16.0), and best neurologic outcomes (mRS 1.7 vs mRS 1.8-2.6). After an ischemic stroke, patients undergoing urgent carotid interventions had the lowest presenting stroke severity (NIHSS) and highest rate of independent neurologic outcomes (mRS) compared with other stroke interventions. Incoming stroke severity correlates with functional neurologic outcomes, and patients who present with an NIHSS of 10 or less who undergo uCEA/uCAS have a high likelihood of independent neurologic functional outcome (mRS of ≤2).

Reducing Inpatient Psychiatric Unit Denials: A Case Management Quality Improvement Project.

The purpose of the inpatient psychiatric unit denials reduction project was to establish a taskforce to analyze denials data for root cause and identify an effective solution to prevent denials through improved provider documentation. The development and implementation of the project occurred at Stanford Health Care, a nonprofit Level 1 trauma hospital, with a 29-bed inpatient psychiatric unit containing both open and secured levels of care. The project was led by the Utilization/Denials Management team, which is subteam within the Case Management Department. Team members are Nurse Case Managers specializing in the management of denials and appeals, data analysis and trending of denials, denial avoidance, and reduction of financial risk. Denials data analysis revealed the Psychiatry Service Line was responsible for over 70% of payer denials within the Length of Stay Write-offs category. In early 2019, the Utilization/Denials Management team initiated a quality improvement project using A3 Lean Approach methodology and evidence-based practice to guide the implementation. The partnership and collaboration included Case Management, Revenue Cycle, Clinical Documentation Improvement, Technology and Digital Solutions, and Psychiatry Service Line leadership that had an interest in reducing payer denials. Outcomes measured for the project were based on denials data for (fiscal year) FY19, the preintervention period, compared to FY20 and FY21, the postintervention period. From FY19 to FY20, revenue loss decreased by 42%. The downward trend continued from FY20 to FY21 with a recorded decrease by 69%. The most important implication of the project was improved physician documentation and medical necessity supporting the severity and intensity of inpatient psychiatric level of care, and medical justification for the inpatient stay not only to prevent medical necessity denials but to accurately reflect the care that was provided. High-quality documentation correlates to the high quality of care being provided. This project is far reaching not only for psychiatric units but also reproducible for other acute hospital service lines. Case Management is a multidisciplinary role, and this work is most meaningful for a Nurse Case Manager engaged in care coordination, including utilization and denials management.

Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department

BackgroundMedical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians. MethodsProspective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa. ResultsA total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49–0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4–66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49–0.60).The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified. ConclusionDigitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.

NeuroMeasures-Implementation of a Web-Based, Real-Time Quality Metric Tool to Improve Provider Practices in an Epilepsy Clinic.

The retrospective nature of most available epilepsy quality improvement (QI) tools focuses on changing health care provider (HCP) clinical habits and documentation practices rather than a focus on real-time patient interventions. Furthermore, patient-reported outcome data are often not available to determine the efficacy of these tools. Our primary objective was to demonstrate the improvement of HCPs' documentation and review of epilepsy quality measures (EQMs) during the patient visit with the implementation of a novel web application, NeuroMeasures. Our secondary objective was to improve the percentage of point-of-care counseling and interventions based on quality measures during the patient encounter based on the results of the NeuroMeasures tool. Our QI study focused on comparing a preintervention and postintervention cohort of patients with epilepsy (PWE) before the implementation of NeuroMeasures, a web-based application that takes a self-guided patient survey through self-scoring algorithms focused on the American Academy of Neurology (AAN)'s 2017 EQMs. This e-tool then provides the HCP a tool to directly review the EQMs highlighted and perform any necessary counseling or interventions at the point-of-care visit. After intervention, EQMs were gained from the review of the NeuroMeasures HCP quality measures tool and a chart review for physician documentation. Patients with language barriers and severe cognitive disabilities were excluded from the study. The preintervention cohort consisted of 150 unique PWE, and the postintervention cohort included 379 unique adult PWE and 515 total encounters. Overall percentages of review/adherence of EQMs were significantly improved between the preintervention and postintervention group for counseling for women of childbearing potential (91.7%), intractable epilepsy referral to a comprehensive epilepsy center (74%), quality of life assessment (80%), improvement of quality of life measurements (41.7%), and depression and anxiety screening (85.6%), demonstrating a significant increase when compared with the preintervention group (p < 0.00001). A web-based point-of-care EQM application demonstrated significant improvement of the HCP's ability to perform and review EQMs at the point-of-care patient visit. Furthermore, the application was successful in creating opportunities for direct intervention based on the EQMs and chances for better patient education and provider-patient communication. Further considerations would include automated survey requests and expansion into other AAN QMs.

Improving Clinical Documentation Compliance Pre-Gastrointestinal Endoscopy Procedures Through the Use of an Endoscopy Checklist.

Production pressure in endoscopy units, to avoid procedural delays, can lead to documentation gaps that pose a patient safety risk. Fast-paced, high-volume endoscopy units within a 673-bed academic medical center, incomplete and illegible documentation were identified during a 2018 Joint Commission survey. Pre-procedure safety checklists help ensure accurate clinical handovers. Checklists promote team communication that includes the patient to have complete and relevant information to perform a safe procedure and speak up to identify discrepancies. An endoscopy-specific safety checklist was used by the procedural team immediately pre-procedure. This quality improvement project used Plan Do Study Act cycles to incorporate changes suggested by users. Chart audits were conducted pre- and post-pilot. The results showed significant improvements in physician documentation completeness and legibility, suggesting the checklist prompted clarification of documentation and communication between the nurse and the physician. Nursing assessment saw a 27.1% improvement, suggesting clarification of clinical handover between the admitting and procedural nurses. Improved communication was perceived by staff. This project showed how a standardized tool to promote team communication and clarification of discrepancies pre-procedure can contribute to prevention of errors.

Hospital practices and clinical outcomes associated with behavioral symptoms in persons with dementia.

Hospitalized persons living with dementia (PLWD) often experience behavioral symptoms that challenge medical care. This study aimed to identify clinical practices and outcomes associated with behavioral symptoms in hospitalized PLWD. A retrospective cross-sectional study. The study included PLWD (65+) admitted to one of severe health system hospitals in 2019. Behavioral symptoms were defined as the presence of (1) a psychoactive medication for behavioral symptoms; (2) an order for physical restraints or constant observation; and/or (3) physician documentation of delirium, encephalopathy, or behavioral symptoms. Associations between behavioral symptoms and patient characteristics and hospital practices (e.g., bladder catheter) were examined. Multivariable logistic/linear regression was used to evaluate the association between behavioral symptoms and clinical outcomes (e.g., mortality). Of hospitalized PLWD (N = 8637), the average age was 84.5 years (IQR = 79-90), 61.7% were female, 60.1% were white, and 9.4% (n = 833) were Hispanic. Behavioral symptoms were identified in 40.6% (N = 3606) of individuals. Behavioral symptoms were significantly associated with male gender (40.3% vs. 36.9%, p = .001), white race (62.7% vs. 58.3%, p < .001), and residence in a facility prior to admission (26.6% vs. 23.7%, p < .001). Regarding hospital practices, indwelling bladder catheters (11.2% vs. 6.0%, p < .001) and dietary restriction (41.9% vs. 33.8%, p < .001) were associated with behavioral symptoms. In multivariable models, behavioral symptoms were associated with increased hospital mortality (odds ratio [OR]: 1.90, CI95%: 1.57-2.29), length of stay (parameter estimate: 2.10, p < .001), 30-day readmissions (OR: 1.14, CI95%: 1.014-1.289), and decreased discharge home (OR: 0.59, CI95%: 0.53-0.65, p < .001). Given the association between behavioral symptoms and poor clinical outcomes, there is an urgent need to improve the provision of care for hospitalized PLWD.

Factors and Outcomes Associated With Dysphagia in Hospitalized Persons With Dementia.

Dysphagia is prevalent in older adults with dementia, particularly in the acute care setting. The objective of this study was to use an innovative approach to extract a more representative sample of patients with dysphagia from the electronic health record (EHR) to determine patient characteristics, hospital practices, and outcomes associated with dysphagia in hospitalized persons with dementia. A retrospective study of hospitalized adults (aged ≥65years) with dementia was conducted in 7 hospitals across the greater New York metropolitan area. Data were obtained from the inpatient EHR with the following inclusion criteria: age ≥65years; admitted to one of 7 health system hospitals between January 1, 2019, and December 31, 2019; and documented past medical diagnosis of dementia (based on International Classification of Diseases, Ninth Revision). A diagnosis of dysphagia was defined as nurse documentation of a positive bedside swallow screening, nurse documentation of "difficulty swallowing" as reason for not performing bedside swallow screening, and physician documentation of a dysphagia diagnosis. Of adults with dementia (N= 8637), the average age was 84.5years, 61.6% were female, and 18.1% were Black and 9.3% Hispanic. Dysphagia was identified in 41.8% (n= 3610). In multivariable models, dysphagia was associated with invasive mechanical ventilation [odds ratio (OR) 4.53, 95% CI 3.55-5.78], delirium (OR 1.53, 95% CI 1.40-1.68), increased length of stay (B= 3.29, 95% CI 2.98-3.60), and mortality (OR 4.44, 95% CI 3.54-5.55). Given its high prevalence, underrecognition, and associated poor outcomes, improving large-scale dysphagia identification can impact clinical care and advance research in hospitalized persons with dementia.

European LeukemiaNet Response Predicts Disease Progression but Not Thrombosis in Polycythemia Vera.

European LeukemiaNet Response Predicts Disease Progression but Not Thrombosis in Polycythemia Vera.

Understanding the path to diagnosis and clinical presentation of patients with PIK3CA-related overgrowth spectrum (PROS) through an innovative patient-centered data platform.

e18707 Background: PROS is a group of rare disorders driven by activating mutations in PIK3CA. Overactivation of the PI3K pathway, which regulates growth and proliferation, results in asymmetric malformations/overgrowths. Localized interventions are often not curative and no medical therapy for PROS is approved; however, mTOR inhibitors (ie sirolimus) are used off-label with modest success. Using a patient (pt)-focused approach, we seek to better understand the current path to diagnosis (dx), course of disease, interventions, and pt outcomes to optimize future therapies. Methods: Pts treated in the US are being actively recruited via interactions with pt advocacy groups, pt communities, social media, and allstripes.com. Following research and HIPAA authorization from each pt/guardian, AllStripes’ proprietary real-world evidence (RWE) platform collects pt medical records into a master medical record from which study data are abstracted. All activities are covered under AllStripes’ IRB-approved protocol. To enroll in the PROS cohort, pts must have a confirmed PROS dx via PIK3CA genetic testing. Data completeness and nomenclature are dependent on physician documentation. Results: To date 14 pts (7 female, 7 male) have enrolled; median age at enrollment was 10.5 y (range, 1-38). Of the 14 pts, 71.4% of pts (n = 10) had congenital onset. PIK3CA genetic testing was primarily (n = 12, 85.7%) completed as a part of a multigene panel. The most frequent specialties involved in dx were medical genetics (n = 4, 28.6%) and pediatric heme-oncology (n = 3, 21.4%). Clinical presentation commonly included vascular malformations (n = 8, 57.1%). Most pts were diagnosed with CLOVES (n = 12, 85.7%). Seven pts (50.0%) had documented lesions at dx, median of 2 (range, 1-13) lesions per pt, increasing after dx to 3 (range, 1-14). All pts reported PROS-related complications; 50.0% (n = 7) required hospitalization/ER visit. Musculoskeletal, neurological, and gastrointestinal related complications were each reported by ≥50% of pts. All pts required ≥1 surgery; ≥50% of pts had diagnostic, debulking, vascular, or other procedures. Median number of surgeries per pt was 7 (range, 1-28), corresponding to a median of 0.76 surgeries per pt per year. Eight pts (57.1%) received PROS related medications: 6 (42.9%) received alpelisib, 5 (35.7%) received sirolimus. Conclusions: While each pt is unique, similarities in the path to dx (eg, specialties involved) and disease history (eg, clinical presentation, symptoms experienced) exist. RWE abstracted from medical records rapidly provides data in an otherwise limited field, helping to address key questions. Preliminary results highlight the burden of PROS and the reliance on repetitive surgical interventions for management, suggesting there remains a high unmet medical need for effective therapeutic strategies.

Feasibility of establishing a multi-center research database using the electronic health record: The PURSUIT network

Although multi-center research is needed in pediatric urology, collaboration is impeded by differences in physician documentation and research resources. Electronic health record (EHR) tools offer a promising avenue to overcome these barriers. To assess the accuracy, completeness, and utilization of structured data elements across multiple practices. A standardized template was developed and implemented at five academic pediatric urology practices to document clinic visits for patients with congenital hydronephrosis and/or vesicoureteral reflux. Data from standardized elements in the template and from pre-existing EHR fields were extracted into a secure database. A 20% random sample of infants with data from structured elements from 1/1/2020 and 4/30/2021 were identified and compared to manual chart review at sites with >100 charts; all other sites reviewed at least 20 charts. Manual chart review was standardized across sites and included: clinic and operative notes, orders linked to the clinic encounter, radiology results, and active medications. Accuracy of data extraction was evaluated by computing the kappa statistic and percentage agreement. For sites that had adopted the templates prior to 6/1/2019 (early adopters), a list of eligible patients with an initial clinic visit from 1/1/2020-7/27/2020 was generated using standardized reporting techniques and confirmed by manual chart review. Physician utilization of the template was then calculated by comparing patients with data obtained from the note template to the generated list of eligible patients. 230 patient records met study criteria. Agreement between manual chart review and data extracted from the EHR was high (>85%). Race, ethnicity and insurance data were misclassified in about 10-15% of cases; this was due to site-specific differences in how these fields were coded. Renal ultrasound was misclassified 12% of the time; this was primarily due to outside images documented in radiology results but not included in the clinical note. All other data elements had >90% agreement (Figure). Template utilization for early adopters was >75% (75.5-87.5%). This is the first study in urology to demonstrate that use of structured data elements can support multi-center research. Limitations include: inclusion of only academic sites with the Epic EHR and lack of data on utilization and sustainability at sites without a prior history of structured template use. Multi-center research collaboration using EHR-based data collection tools is feasible with generally high accuracy compared to manual chart review. Additionally, sites with a long history of template adoption have high levels of provider utilization.

Documentation of Consent Practices for Assisted Vaginal Births (AVB) at Two Tertiary Care Hospitals: A Retrospective Review of Physician Documentation

Documentation of Consent Practices for Assisted Vaginal Births (AVB) at Two Tertiary Care Hospitals: A Retrospective Review of Physician Documentation

Determining consistency of care after resuscitation from in-hospital cardiac arrest, a retrospective analysis at a tertiary care academic medical center

BackgroundFew guidelines have focused on the care delivered after return of spontaneous circulation (ROSC). Post ROSC best practice guidelines lack clarity about important tasks to accomplish in the first hours after ROSC. Objectives and methodsWe conducted a retrospective cohort analysis of adults who had suffered an in hospital cardiac arrest (IHCA) with ROSC over a two-year period to determine the completion rate of critical tasks in the immediate post-ROSC period: ECG within one hour, ABG within one hour, physician documentation within six hours, and surrogate communication within six hours. ResultsIn the 113 reviewed cases, there was significant variance between completion of all four (19.4%), three (35.3%), two (32.7%), one (20.6%) and none (1.7%) of these critical post ROSC tasks. We observed that 62.8% of IHCA with ROSC had an ECG obtained within one hour of ROSC. The rate of obtaining an ABG within one hour of ROSC was 76.9%. 49.5% of cases had physician documentation of the resuscitation within six hours of ROSC. The rate of documenting surrogate communication within six hours of ROSC was 69.9%. ConclusionsOur study demonstrated that the completion rates of critical tasks in the post ROSC setting were suboptimal within our patient cohort. This provides a baseline for the development of future best practice guidelines and clinical decision-making aids for post ROSC care after IHCA. This can lead to future research in coupling specific care tasks to post ROSC patient outcomes.

Retrospective descriptive assessment of clinical decision support medication-related alerts in two Saudi Arabian hospitals

ObjectivesTo determine the frequency of clinical decision support system (CDSS) medication-related alerts generated, accepted, or overridden, to assess appropriateness of alert display and overrides, and to characterise the documentation of clinician justification for these overrides in an academic medical centre in Saudi Arabia.Materials and methodsSystem-generated CDSS reports for the period June 2015 to December 2017 were retrospectively reviewed and analysed. Alerts were classified into different types, and rates of alert overrides calculated as percentages of all generated alerts. A subset of 307 overridden alerts was assessed for appropriateness of display and override by two clinical pharmacists. Physician documentation of reasons for overriding alerts were categorised.ResultsA total of 4,446,730 medication-related alerts were generated from both inpatient and outpatient settings, and 4,231,743 (95.2%) were overridden. The most common alert type was ‘duplicate drug’, accounting for 3,549,736 (79.8%) of alerts. Of 307 alerts assessed for appropriateness, 246 (80%) were judged to be appropriately displayed and 244 (79%) were overridden appropriately. New drug allergy and drug allergy alerts had the highest percentage of being judged as inappropriately overridden. For 1,594,313 alerts (37.7%), ‘no overridden reason selected’ was chosen from the drop-down menu.ConclusionsThe alert generation and override rate were higher than reported previously in the literature. The small sample size of 307 alerts assessed for appropriateness of alert display and override is a potential limitation. Revision of the CDSS rules for alerts (focusing on specificity and relevance for the local context) is now recommended. Future research should prospectively assess providers’ perspectives, and determine patient harm associated with overridden alerts.

Assessing the Status of Tools and Methods for Evaluating Physicians' Documentation in the Emergency Department: A Review Study

Introduction: Documentation of medical records is the first and most important source of patient information collection. On the other hand, the correct registration of medical records is considered as one of the criteria of physicians' scientific skills. Therefore, the purpose of this study was a systematic review to examine the status of tools and methods for evaluating the documentation of physicians in the emergency department.Material and Methods: This systematic review was performed in studies related to the evaluation of the documentation status of emergency department physicians. The studies were available from PubMed, Web of Science, Scopus, Irandoc and SID databases by the end of 2020. Titles and abstracts were reviewed independently based on eligibility criteria. After that, the complete texts were retrieved and independently reviewed by two researchers based on eligibility criteria. A standardized form was used to extract the data including study title, first author name, years of study, place of study, number of samples, research method, tools, indicators studied and main findings.Results: A total of 4693 related studies were extracted from the database and finally 40 main articles were included in the study. In 4 cases, the level of documentation was reported to be incomplete and undesirable by examining the registered files; In the other 4 cases, they estimated the amount of documentation as moderate to favorable. In 2 cases, the effect of education and in 2 cases, the effect of feedback and encouragement on documentation were measured. None of the studies provided a comprehensive tool for evaluating physicians' documentation of emergencies; Evaluation patterns were different in each study and were partially reviewed.Conclusion: A review of research conducted in Iran and the world on documenting physicians, especially in the emergency department, emphasizes the importance of continuing the process of patients. Consequently, the consequences are the same for all stakeholders in the medical record. In addition, the effect of feedback and encouragement was more effective than training in improving documentation, so it is suggested that programs be applied for ongoing feedback to documentarians.

Inpatient Coding System and Opportunities for Documentation Optimization: An Interactive Session for Internal Medicine Residents.

IntroductionThe Inpatient Prospective Payment System, the framework for categorization of admissions, is based upon physician documentation leading to International Classification of Diseases, Tenth Revision code generation and Medical Severity Diagnosis-Related Group (MS-DRG) assignment. In this curriculum, we introduced internal medicine residents to this inpatient coding framework and its effects on hospital quality metrics and reimbursement. We focused on educating learners about the importance of physicians being proficient in providing thorough and specific clinical documentation to produce appropriate DRG assignment.MethodsInternal medicine residents participated in a 90-minute session that introduced the basic framework of inpatient coding, discussed effects of physician documentation on hospital quality metrics and reimbursement, and provided tips on opportunities for documentation improvement. In an interactive learning activity, residents were presented with clinical vignettes and earned reimbursement based on their documentation of appropriate diagnoses. Each scenario was followed by clinical definitions and actionable documentation recommendations for common diagnoses. Materials included a PowerPoint presentation, clinical vignettes, sample teaching points, and a rubric to calculate estimated reimbursement.ResultsPrior to the session, 38% of learners were confident in their understanding of how documentation affects hospital reimbursement, which improved to 90% postsession. Learners reported improvement in their knowledge of documentation requirements for all targeted diagnoses.DiscussionThis interactive curriculum improved resident knowledge of the inpatient coding system and documentation requirements for common diagnoses and addressed a deficiency in residency education on a topic of significant importance for the success of hospital systems.

Content of physical activity documentation in Canadian family physicians' electronic medical records.

The purpose of this study was to examine the content of physical activity inputs in Canadian family physician electronic medical records. Of 1 225 948 patients aged 18-64years, a sample of 1535 patients' charts were reviewed. A minority (n = 148; 9.6%) of patients had at least 1 mention of physical activity at any time. Insufficient information existed to determine physical activity domain (21.6%), purpose (50.0%), or meeting of guidelines (98.1%). Novelty: This study examines the physical activity content of what Canadian family physicians document in their electronic medical records.

Infant Feeding Clusters Are Associated With Respiratory Health and Allergy at School Age in the PARIS Birth Cohort

To identify first year of life feeding cohorts and examine associations between respiratory health and allergy at 8 years of age and infant feeding practices.A total of 3446 infants born in Paris, France, were managed from birth to 8 years of age.Questionnaires were collected at 1,3,6,9, and 12 months of life, focusing on breastfeeding, consumption of infant formula (regular, partially hydrolyzed, extensively hydrolyzed, prebiotics and probiotics, and soy), and solid food introduction. Multidimensional longitudinal cluster analysis was used to place children with similar early feeding practices into 5 cohorts. Standardized questionnaires, physician documentation, lung function, fractional exhaled nitric oxide, and specific immunoglobulin E were collected at 8 years of life. These data were used to identify atopic morbidity correlations between feeding cohorts. Multivariable logistic and linear regression models adjusted for early respiratory and allergic outcomes and parental history of allergy.Participants were grouped into 5 feeding clusters on the basis of early feeding patterns: cluster 1 (45%): mostly regular formula; cluster 2 (27%): exclusively breastfed during the first 3 months; cluster 3: (17%) prebiotic or probiotic formula; cluster 4: (7%) partially hydrolyzed formula, and cluster 5: (4%) extensively hydrolyzed or soy formula. Compared with infants in cluster 1, children fed extensively hydrolyzed or soy formula were more likely to have diagnosis of food allergy (cluster 5). Infants fed partially hydrolyzed formula (cluster 4) had a significant lower lung function (forced expiratory volume in 1 second; forced vital capacity), higher fractional exhaled nitric oxide, and higher risk of allergic sensitization at 8 years of life, compared with that of cluster 1. Compared with infants fed mostly regular formula (cluster 1), infants exclusively breastfed during the first 3 months (cluster 2) had a lower rate of asthma diagnosis.Children breastfeeding at least 3 months in this study had protection against developing asthma and food allergy later in life, compared with other feeding groups. Infants with early partially hydrolyzed formula had higher rates of asthma and atopy at 8 years of age, even while controlling for early respiratory or allergic disease and family history of atopy.This supports previous recommendations regarding breastfeeding and the prevention of atopic conditions. The authors caution pediatricians against recommending hydrolyzed or hypoallergenic formulas universally or on the basis of family history alone and highlight potential future morbidity. This study revealed no benefits in preventing atopic disease with prebiotic or probiotic formulas, although the grouping of multiple different types of these formulas in 1 heterogenous group is a significant study limitation. The mechanisms underlying these results deserve further study.

Utilization of Automated Keyword Search to Identify E-Scooter Injuries in the Emergency Department.

Background and objectiveAccurate identification and categorization of injuries from medical records can be challenging, yet it is important for injury epidemiology and prevention efforts. Coding systems such as the International Classification of Diseases (ICD) have well-known limitations. Utilizing computer-based techniques such as natural language processing (NLP) can help augment the identification and categorization of diseases in electronic health records. We used a Python program to search the text to identify cases of scooter injuries that presented to our emergency department (ED).Materials and methodsThis retrospective chart review was conducted between March 2017 and June 2019 in a single, urban academic ED with approximately 80,000 annual visits. The physician documentation was stored as combined PDF files by date. A Python program was developed to search the text from 186,987 encounters to find the string “scoot” and to extract the 100 characters before and after the phrase to facilitate a manual review of this subset of charts.ResultsA total of 890 charts were identified using the Python program, of which 235 (26.4%) were confirmed as e-scooter cases. Patients had an average age of 36 years and 53% were male. In 81.7% of cases, the patients reported a fall from the scooter and only 1.7% reported wearing a helmet during the event. The most commonly injured body areas were the upper extremity (57.9%), head (42.1%), and lower extremity (36.2%). The most frequently consulted specialists were orthopedic and trauma surgeons with 28% of cases requiring a consult. In our population, 9.4% of patients required admission to the hospital.ConclusionsThe number of results and data returned by the Python program was easy to manage and made it easier to identify charts for abstraction. The charts obtained allowed us to understand the nature and demographics of e-scooter injuries in our ED. E-scooters continue to be a popular mode of transportation, and understanding injury patterns related to them may inform and guide opportunities for policy and prevention.