Progress Note Research Articles

Back to Babies: Reducing Documentation Time in the NICU

Abstract Background There is no accepted best practice for generation and content of daily progress notes in the neonatal intensive care unit (NICU). Objectives This study aimed to implement a consistent documentation standard process for a neonatology provider group at a level IV tertiary care NICU. The primary aim was to improve timeliness of daily progress note completion. Secondary aims were to maintain or improve clinician satisfaction, reduce variability, and reduce attending neonatologist electronic medical record (EMR) documentation tasks. Methods We formed a work group including advanced practice providers (APPs) and physicians from the NICU that met over 6 months to define the ideal NICU documentation content, map the workflow for documentation, identify gaps in EMR content, and create solutions for each gap. Baseline assessment included a change readiness survey to identify barriers to workflow change and a review of neonatologist signature timestamp to determine time to note completion. Twenty random progress notes were sampled weekly for 6 months prior to implementation of new workflow as well as 6 months postimplementation. Average time to note completion was compared in the pre- and postintervention groups. Results In total, 962 notes were sampled, 481 each in the pre- and postintervention states. Twenty neonatologists were captured in the preintervention state, 24 in the postintervention state, 18 were captured in both samples. Final note completion time mean improved from 10 hours and 32 minutes (from starting note to final sign) to 8 hours and 40 minutes (p < 0.01). Those sampled in both epochs improved from 10 hours and 6 minutes to 8 hours and 30 minutes (p < 0.05). Conclusion Progress notes generated by neonatologists are completed earlier than those generated by an APP with a Neonatologist addendum. Specialty-specific education and training are critical to high satisfaction in large EMR workflow transitions.

CHIVID: A Rapid Deployment of Community and Home Isolation During COVID-19 Pandemics.

CHIVID is a telemedicine solution developed under tight time constraints that assists Thai healthcare practitioners in monitoring non-severe COVID-19 patients in isolation programs during crises. It assesses patient health and notifies healthcare practitioners of high-risk scenarios through a chatbot. The system was designed to integrate with the famous Thai messaging app LINE, reducing development time and enhancing user-friendliness, and the system allowed patients to upload a pulse oximeter image automatically processed by the PACMAN function to extract oxygen saturation and heart rate values to reduce patient input errors. This article describes the proposed system and presents a mixed-methods study that evaluated the system's performance by collecting survey responses from 70 healthcare practitioners and analyzing 14,817 patient records. Approximately 71.4% of healthcare practitioners use the system more than twice daily, with the majority managing 1-10 patients, while 11.4% handle over 101 patients. The progress note is a function that healthcare practitioners most frequently use and are satisfied with. Regarding patient data, 58.9%(8,724/14,817) are male, and 49.7%(7,367/14,817) within the 18 to 34 age range. The average length of isolation was 7.6 days, and patients submitted progress notes twice daily on average. Notably, individuals aged 18 to 34 demonstrated the highest utilization rates for the PACMAN function. Furthermore, most patients, totaling over 95.52%(14,153/14,817), were discharged normally. The findings indicate that CHIVID could be one of the telemedicine solutions for hospitals with patient overflow and healthcare practitioners unfamiliar with telemedicine technology to improve patient care during a critical crisis. Clinical and Translational Impact Statement- CHIVID's success arises from seamlessly integrating telemedicine into third-party application within a limited timeframe and effectively using clinical decision support systems to address challenges during the COVID-19 crisis.

“But I didn’t understand your handwriting!” Uncovering the significance of therapy progress notes for parents in music therapy

In this piece, I will explore a mistake I made by randomly handing a progress note to a parent at the end of a music therapy session, while overlooking the power imbalances embedded in such an act. I will share a clinical vignette involving Xavier, the father of a little girl named Blossom, who was only 10 months old, had many physical challenges, had severely impaired eyesight, and at the time could only sparsely respond to her loving environment. I will begin by describing a moment in the session when the father expressed his frustration from not being able to understand my handwriting in the progress note handed to him. Then, I will explore the unattended, underlying cultural and relational gaps in therapy that were captured in the virtually unnoticed gesture of handing a parent a scribbled progress note. Finally, I will examine the therapeutic requests expressed in such an important critique, which I failed to acknowledge as the family's therapist, focusing on aspects relating specifically to music therapy.

Methodological progress note: De-implementation of low-value care.

Methodological progress note: De-implementation of low-value care.

Determinants and Disparities of Neurosurgery Patients Refusing Inpatient Palliative Care After Provider Recommendation.

Background Disparities have been found in the utilization of palliative care (PC). However, a limitation of existing research is that it co-mingles factors affecting whether a patient is offered PC with factors affecting whether a patient accepts/refuses PC. Our objective is to identify the determinants and disparities of neurosurgery patients accepting/refusing inpatient PC after a provider recommends an inpatient PC consult. Methodology In this single-center retrospective cohort study, the last 750 consecutive neurosurgery patient medical records were screened. Inclusion criteria were as follows: (1) the patient was seen by the neurosurgery service during their hospitalization and (2) the patient had a documented inpatient PC consult ordered or the patient had at least one progress note documenting PC in the plan of care. Excluded were patients not seen by the neurosurgery service during the hospitalization in which the PC consult order or plan was documented. Analysis was performed using multivariate logistic regression with backward stepwise variable selection. Candidate variables included age, gender, race, ethnicity, language, marital status, insurance type, surrogate decision-maker (SDM) relationship to patient, advanced directive, Charlson Comorbidity Index (CCI), ambulation, activities of daily living (ADL) dependence, primary diagnosis category, Glasgow Coma Scale (GCS) at the time of admission, GCS at the time of PC consult, GCS at the time of discharge, duration of hospitalization, and hospitalization mortality. Results Of the last 750 neurosurgery patients, this study included 144 patients (33.3% female; mean age 57.53±19.89 years). Among these patients, 109 patients (75.7%) accepted PC and 35 patients (24.3%) refused PC. Univariate analysis showed that patients refusing PC tended to be older (p=0.003) and have a shorter duration of hospitalization (p=0.023). Chi-squared analysis found associations between PC acceptance/refusal and preferred language (p=0.026), religion (p<0.001), and SDM relationship to patient (p=0.004). Multivariate logistic regression found that predictors of PC refusal were older age (OR=0.965, p=0.049), non-English (OR=0.219, p=0.004), adult child SDM (OR=0.246, p=0.023), and other relative/friend SDM (OR=0.208, p=0.011). Religious patients were more likely to accept PC (OR=7.132, p<0.001). Race and ethnicity factors were not found to be significant predictors of PC refusal: Black (p=0.649), other race (p=0.189), and Hispanic (p=0.525). Conclusion Nearly one-quarter of neurosurgery patients offered PC refused this care. Predictors of PC refusal were older age, non-English, adult child SDM, and other relative/friend SDM. Religious patients were more likely to accept PC. Race and ethnicity were not found to be significant predictors of accepting/refusing PC, which may suggest these previously identified disparities stem from minority patients being offered less PC. Additional research is needed to replicate these findings among different patient populations. Because PC is compatible with life-prolonging therapies and aims to provide additional emotional and spiritual support to the patient and family, the finding that nearly one-quarter of patients refused PC may demonstrate a pervasive misconception and need for patient education.

Knowing the Dose to Control the Dose: Optimizing Patient-Controlled Analgesia in Adults with Sickle Cell Disease (SCD)

Introduction: Acute painful episodes are the most common cause of hospitalization in SCD. Intravenous (IV) opioids are the analgesic of choice to treat pain requiring hospitalization in adults. On-demand IV opioid dosing can be either via a patient-controlled analgesia (PCA) pump or via intermittent nurse bolus. Advantages of PCA include better analgesia accessibility and relative independence from staff. However, significant variability exists in PCA management. A multicenter, randomized-controlled trial of PCA strategies in SCD was terminated early due to slow accrual, stemming from barriers such as suboptimal communication between inpatient teams. Additional limitations with PCA include technological limitations and incomplete charting through a manual process. We initiated a quality improvement project to understand patterns of PCA use in patients hospitalized for SCD pain crises at our institution. Methods: We performed a retrospective manual chart review on all adult patients diagnosed with SCD pain crises admitted to the University of Cincinnati Medical Center (UCMC) from October 1 through December 31, 2022. Inpatient data collected included reason for admission, length of stay, and documentation of inpatient opioid usage in daily clinical notes. Hospitalizations requiring intensive care admission for severe complications were excluded. Outpatient data collected included demographics and outpatient opioid prescriptions via the state prescription drug monitoring database. The study was approved by the UCMC IRB. Results: Fifteen patients were admitted to UCMC a total of 24 times for SCD pain crises during the 3-month period. The patients ranged in age from 21 years to 73 years (median age 33 years, interquartile range (IQR) 19.5 years) and the majority (11/15) were women. Disease-modifying therapies prescribed included hydroxyurea (8/15, 53%), chronic transfusions (2/15, 13%), chronic transfusions plus hydroxyurea (1/15), voxelotor (1/15), no disease-modifying therapy (2/15). Nine patients were prescribed daily outpatient opioids that included an oral long-acting opioid plus an oral short-acting opioid. Out of the 24 hospitalizations, 11 were for an uncomplicated pain crisis, 10 were complicated by mild acute chest syndrome (mild hypoxia and/or abnormal chest imaging), and 3 patients experienced other treatable complications (2 with Staphylococcus epidermidis bacteremia, 1 with deep venous thrombosis). Five patients were admitted two or more times. Two patients, admitted a total of 5 times, were maintained on nurse-administered IV bolus opioids during their admissions, in addition to oral opioids. The remainder of the patients were treated with a hydromorphone PCA pump with on-demand bolus dosing only, in addition to home long-acting oral opioids when applicable. Two patients were ultimately transitioned from PCA onto nurse-administered bolus IV opioids, due to failure to achieve adequate analgesia with PCA. In 9 out of the 19 admissions using a PCA, daily MME or the equivalent was charted in at least one progress note (47%). The median LOS in the subgroup in which PCA use was charted at least once was 7 (IQR 3.5) days. In the 10 admissions on a PCA in which daily MME was never charted (53%), the median LOS was 11 (IQR 6.25) days. Among patients not receiving outpatient opioids, daily MMEs from the PCA in the first few days of hospitalization (when recorded) ranged from 24 to 520 (median 178, IQR 241) MME. In patients who had daily chronic pain on outpatient opioid therapy, daily inpatient MME from PCA ranged from 360 to 1020 (median 545, IQR 418) MME. In patients with multiple admissions during the study period, the recorded daily opioid use was about two times that in the single admission group (median 673, IQR 500 MME in the multiple admissions group; vs median 329, IQR 351 MME in the single admission group). Conclusions: Our data suggest that length of stay is shortened by ~4 days when clinicians quantify daily opioid use for patients on PCA. In addition, patients with frequent admissions tend to have higher inpatient daily opioid use. This hints that readmission may be partly driven by mild withdrawal when on outpatient opioids at lower MME. A major barrier to data collection was inconsistent documentation of daily opioid use. The next step in our quality improvement project is an educational curriculum on inpatient opioid management for residents and hospitalists.

Social Determinants of Health: A Multilingual Standardized Patient Case to Practice Interpreter Use in a Telehealth Visit.

The growing diversity of the United States population and strong evidence of disparities in health care make it critically important to educate health care professionals to effectively address issues of culture. To that end, we developed a simulation for teaching interpreter use in a telehealth setting. Our contribution of non-English language preference (NELP) patient cases in Spanish, Tagalog, French, and Igbo advances existing literature by combining the skills of interpreter use and telehealth while widening the array of cultures represented. Simulations were implemented for two cohorts of 60 first-year medical students. In the pilot, nine groups of six to seven students and one faculty met via Zoom with an NELP patient complaining of fatigue, weakness, and cough. When students determined the need for an interpreter, faculty admitted one to the meeting, and the telehealth visit continued. Postsession activities included debriefing and writing a progress note. Course evaluation comments from the first cohort and a postencounter survey of the second cohort were positive. They revealed that students learned to speak slower, in shorter phrases, and directly to the patient. Learners completed note documentation according to a rubric. This low-stakes activity provides faculty with a resource for introducing cultural competence into the curriculum. The original Spanish version of the case has been translated into three additional languages, providing a diverse representation of the NELP population. Important points for communicating through an interpreter are practiced in a telehealth setting with a fatigue case.

Abstract 12752: Comparing Informatics Methods to Identify Guideline Directed Therapy From the Electronic Health Record

Introduction: AHA Get with The Guidelines (GWTG) is a proven in-hospital approach to improving patient outcomes. The Heart Failure (HF) quality measures for quadruple therapy includes angiotensin receptor/neprilysin inhibitors, beta blockers, aldosterone receptor antagonists, and sodium-glucose transport inhibitors, device counseling, vaccination status assessment, and follow up. Capturing guideline directed therapy (GDT) retrospectively can be done in several ways including the current process of manual review of electronic records, abstraction, and submission to the HF Registry. A SmartPhrase can contribute to adherence of GDT at discharge more efficiently. Research Question: Our research question was, “Can the use of a SmartPhrase improve adherence to AHA HF guidelines?” Goal: To prompt clinicians to address GDT to meet the quality metrics endorsed by the AHA by providing a template for documentation of these therapies in the discharge summary or progress note. Methods: We compared our adherence to the GWTG-HF quality measures prior to after implementing a standard HF DC Checklist SmartPhrase. We evaluated whether the improvement was associated with the SmartPhrase. A Health Information student undertook a project with her preceptor, a Quality Data Manager to analyze SmartPhrase use by providers. Results: We found significant improvement in most GWTG-HF quality measures, including GDT quadruple therapy post-sharing this SmartPhrase. Downstream potential benefits to improved adherence to these HF GDT metrics are improvement in 30-day readmissions. Positive trends in the GWTG-HF quality metrics included an overall improvement from Q1 2022 baseline data for quadruple GDT therapy of 37.2% to Q1 2023 of 80.4%. Conclusions: The adoption of the SmartPhrase improved adherence to the quality metrics. Use of the SmartPhrase varied by provider. Providers used the dot phrase as it was given to them by the team or by copying and pasting the phrase. The use of copy and paste made tracking the use of the SmartPhrase difficult to track electronically. We are exploring additional methods to improve efficient documentation including natural language (NLP).

Impact of targeted education on adverse drug reaction documentation in cancer center sites.

395 Background: Allergic and infusion-related reactions represent a significant portion of reported adverse drug reactions (ADRs) at The University of Kansas Health System (TUKHS) Cancer Center sites. According to the TUKHS Allergy Documentation policy, all observed reactions are required to be documented in the electronic health record (EHR) and reported to the responsible provider. Insufficient documentation may result in preventable patient harm due to continued exposure to medications after known ADRs. An audit of patient EHRs demonstrated notable variability in documentation practices, which served as the impetus to implement a standardized ADR documentation workflow at Cancer Center sites. Methods: This multi-center, retrospective study included patients with ADRs submitted via safety reports from July 1st, 2022 to April 1st, 2023. Categorical data was analyzed using the chi-squared test. Duplicate reports and ADRs identified as side-effects were not included in the final analysis. Targeted education was provided via two online video modules, a workflow tips sheet, and an educational infographic. The primary outcome was frequency of allergy lists updated following submission of a safety event report. Secondary outcomes included frequency of standardized progress note writing, note routing, and accurate reaction type differentiation. Results: Targeted education significantly improved allergy list updating from 34.2% to 84.0% (P &lt; 0.001), use of a standardized progress note from 47.4% to 64.2% (P = .008), and correct differentiation of reaction type from 57.7% to 76.4% (P = .02). Progress notes were routed to the responsible provider 58.5% of the time. Smaller community-based Cancer Center sites were significantly less likely to update allergy lists (7.5% vs. 24.5%, P = .017) and more likely to document incorrect reaction types (35.0% vs. 14.3%, P = .022). Conclusions: Targeted education for a standardized documentation workflow increased adherence to ADR documentation, ensuring future treatment plans are updated for patients with a history of reaction and the EHR accurately reflects ADR history. There is an opportunity to strengthen targeted education surrounding ADR documentation workflows for smaller community-based sites.

A methodological progress note: Introducing qualitative focus group research and the brainwriting premortem.

A methodological progress note: Introducing qualitative focus group research and the brainwriting premortem.

The Impact of Documentation Workflow on the Accuracy of the Coded Diagnoses in the Electronic Health Record

To determine the impact of documentation workflow on the accuracy of coded diagnoses in electronic health records (EHRs). Cross-sectional study. All patients who completed visits at the Casey Eye Institute Retina Division faculty clinic between April 7, 2022 and April 13,2022. Agreement between coded diagnoses and clinical notes. We assessed the rate of agreement between the diagnoses in the clinical notes and the coded diagnosis in the EHR using manual review and examined the impact of the documentation workflow on the rate of agreement in an academic retina practice. In 202 visits by 8 physicians, 78% (range, 22%-100%) had an agreement between the coded diagnoses and the clinical notes. When physicians integrated the diagnosis code entry and note composition, the rate of agreement was 87.9% (range, 62%-100%). For those who entered the diagnosis codes separately from writing notes, the agreement was 44.4% (22%-50%, P < 0.0001). The visit-specific agreement between the coded diagnosis and the progress note can vary widely by workflow. The workflow and EHR design may be an important part of understanding and improving the quality of EHR data. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Nephrology-Palliative Care Collaboration to Promote Outpatient Hemodialysis Goals of Care Conversations.

Goals of care conversations and corresponding life-sustaining treatment (LST) progress notes were completed for only one-fourth of patients on outpatient dialysis despite hospital-wide training with nephrologists at the Edward Hines, Jr. Veterans Affairs Hospital. The purpose of this quality improvement project was to increase completion of LST progress notes and corresponding orders among patients on dialysis through an interdisciplinary nephrology-palliative care collaboration. The nephrology and palliative care departments began an interdisciplinary collaboration for nephrology to consult palliative care to initiate goals of care conversations and complete LST progress notes with patients on dialysis. A coordinated workflow process was created that included multidisciplinary efforts for patient selection, patient education, and introduction and completion of goals of care conversations for patients on dialysis. Completion rates for LST notes increased from 27% to 81% following the 13-month intervention, with 69 of 85 patients having a documented LST progress note. A collaboration between nephrology and palliative care increased high-quality LST progress note completion. The next steps include expanding these collaborations at other dialysis units and evaluating the impact on patient outcomes.

Clinical progress note: Diagnostic error in hospital medicine.

Clinical progress note: Diagnostic error in hospital medicine.

Assessing Primary Care Blood Pressure Documentation for Hypertension Management During the COVID-19 Pandemic by Patient and Provider Groups

BackgroundPrimary care electronic medical record (EMR) data can be used to identify, manage, and screen hypertension cases. However, this approach relies on completeness and accessibility of documented blood pressure (BP) values. With the large switch to virtual care due to the COVID-19 pandemic, we assessed BP documentation in primary care EMRs during the pandemic, across patient and physician groups. MethodsHypertension-related visits were identified during the pre-pandemic (January 2017 to February 2020) and pandemic (March 2020 to December 2021) periods from a primary care EMR database in Ontario, Canada. Clustered logistic regression models were used to analyze the relationship of physician and patient characteristics with an outcome variable of documented BP. A chart review of 3200 hypertension visits without a BP recorded in structured data fields was conducted to determine if BP was recorded in progress notes. ResultsPre-pandemic, 75.7% of hypertension-related visits (113,966 of 150,511) had a BP recorded in structured documentation, but this significantly decreased to 36.4% (26,660 of 73,239) during the pandemic (odds ratio [OR] = 0.18, 95% confidence interval [CI]: 0.18-0.19). For virtual visits, 14.3% (6357 of 44,572) had a documented BP, vs 74.0% (20,056 of 27,089) for in-person visits. Chart review found that 55.9% of hypertension visits had no associated BP in structured documentation, but did have a BP recorded in the progress note. Male providers, compared to female providers, were less likely to record BPs pre-pandemic (OR = 0.45, 95% CI: 0.32-0.63) and during the pandemic, for both virtual visits (OR = 0.48, 95% CI: 0.32-0.71) and in-person visits (OR = 0.46, 95% CI: 0.33-0.64). ConclusionsBP documented in primary care EMRs declined during the pandemic, most likely due to high rates of virtual visits impacting hypertension detection and management.

Clinical progress note: Management of adult restrictive eating disorders in general medical units.

Clinical progress note: Management of adult restrictive eating disorders in general medical units.

Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland

Cisgender women account for one of every five new U.S. HIV diagnoses, with the majority (86%) attributed to heterosexual contact. HIV pre-exposure prophylaxis (PrEP) is an effective prevention strategy; however, PrEP awareness and prescriptions among women are low. Our objective was to increase PrEP counseling and uptake among cisgender women attending obstetrics/gynecology (OB/GYN) clinics. The study included three OB/GYN clinics within a single health system in a high HIV prevalence region. There were three phases: baseline (three-month period before the clinical trial that included provider education and training of a registered nurse about PrEP [PrEP-RN]), clinical trial (three-month period during which eligible patients were randomized to an active control or PrEP-RN intervention), and maintenance (three-month period after the trial ended). Electronic medical record (EMR) clinical decision support tools (CSTs) were available to both arms during the clinical trial, which included best practice alerts (BPAs), order sets, progress note templates, and written and video PrEP educational materials for patients. In the intervention arm, a PrEP-nurse contacted and counseled patients, and was equipped to prescribe PrEP. We evaluated the phases through the RE-AIM framework (Reach-Effectiveness-Adoption-Implementation-Maintenance). The primary outcome of the study was effectiveness (e.g., percentage of eligible patients with documented HIV prevention counseling in the EMR or PrEP prescriptions). Secondary outcomes included reach (e.g., percentage of BPAs that providers acted upon or the percentage of eligible patients who spoke with the PrEP-RN), adoption (e.g., percentage of eligible patients with a BPA that triggered or the percentage of eligible patients the PrEP-RN attempted to contact), and maintenance (e.g., percentage of patients with documented HIV prevention counseling or PrEP prescriptions during the maintenance phase). There were 904 unique patients in all phases with a mean age of 28.8+/-7.7 years, and 46% were pregnant; 436 patients were randomized in the clinical trial phase. Reach/Adoption: BPAs were triggered for 100% of eligible encounters; however, providers acted on 52% of them. The PrEP nurse attempted to contact every patient and successfully spoke with 81.2% of them in the PrEP-RN arm. Compared to the active control, there were significantly more patients counseled about PrEP in the PrEP-RN group (66.5% vs. 12.3%, p<0.001), while PrEP prescriptions were equivalent (p=1.0). Among the subgroup of patients who were counseled about PrEP, 18.5% of patients in the active control and 3.4% in the PrEP-RN arm were prescribed PrEP (p=0.02). Maintenance: CSTs alone resulted in PrEP counseling of 1.0% of patients during the maintenance phase versus 0.6% during baseline and 11.2% during the clinical trial (p<0.001). PrEP prescriptions were not statistically different between the three phases (p=0.096). A PrEP nurse effectively increased HIV prevention discussions but did not lead to more PrEP prescriptions than the PrEP-focused CSTs used by providers. The decrease in PrEP counseling following the trial phase suggests that persistent interventions are needed to maintain effects.

Clinical progress note: Update in management in community acquired pneumonia in children.

Clinical progress note: Update in management in community acquired pneumonia in children.

Utilizing admission ordersets and progress note templates to facilitate Identification and treatment of iron deficiency anemia in the hospitalized heart failure patient.

Utilizing admission ordersets and progress note templates to facilitate Identification and treatment of iron deficiency anemia in the hospitalized heart failure patient.

Clinical progress note: Multiplex panels for identifying infection in children.

Clinical progress note: Multiplex panels for identifying infection in children.

Methodological progress note: Implementation science contributions to healthcare research and practice.

Methodological progress note: Implementation science contributions to healthcare research and practice.