Progress Note Research Articles

Improving On-time Administration of the Initial Hepatitis B Vaccine in the NICU.

Despite the updated American Academy of Pediatrics recommendation for universal administration of the hepatitis B vaccine for newborns, delays in routine prophylaxis are common in the Neonatal Intensive Care Unit (NICU). Delayed immunization can increase perinatal acquisition risks and lead to subsequent delays in routine childhood immunization. This study aimed to increase the on-time administration of the birth dose of the hepatitis B vaccine from 46% to ≥70% at a level III and level IV NICU within the same health system. The stakeholder group developed project interventions using quality improvement methods, including implementing unit guidelines and a prompt in the progress note template. The outcome measure was the percent on-time administration of the initial hepatitis B vaccine for inborn NICU patients born to hepatitis B-negative mothers. The process measure was the percent on-time administration or a valid reason to delay immunization following the guidelines. Statistical process control P-charts graphically represented the measures to assess for change from January 2019 to May 2021. In total, 2192 patients were included. The percent on-time administration improved from 48% to 57%. The percentage of on-time administration or valid reason to delay increased from 76% to 80%. Quality improvement methodology facilitated the identification of barriers to on-time hepatitis B prophylaxis in the NICU and the improvement of the timeliness of administration across 2 sites. Guidelines tailored to this population and changes to the progress note template successfully created and sustained change and may benefit other NICUs.

Descriptive Analysis of Documentation Time for the National Developmental-Behavioral Pediatric Physician Workforce Using a Commercial Electronic Health Record System.

The national developmental-behavioral pediatric (DBP) workforce struggles to meet current service demands because of several factors. Lengthy and inefficient documentation processes are likely to contribute to service demand challenges, but DBP documentation patterns have not been sufficiently studied. Identifying clinical practice patterns may inform strategies to address documentation burden in DBP practice. Nearly 500 DBP physicians in the United States use a single commercial electronic health record (EHR) system (EpicCare Ambulatory, Epic Systems Corporation, Verona WI). We evaluated descriptive statistics using the US Epic DBP provider data set. We then compared DBP documentation metrics against those of pediatric primary care and selected pediatric subspecialty providers who provide similar types of care. One-way analyses of variance (ANOVAs) were conducted to determine whether outcomes differed among provider specialties. We identified 4 groups for analysis from November 2019 through February 2020: DBP (n = 483), primary care (n = 76,423), pediatric psychiatry (n = 783), and child neurology (n = 8589). Post hoc pairwise comparisons revealed statistically significant differences between multiple outcome-specialty combinations. Time in notes per appointment and progress note length demonstrated the strongest evidence of an increased burden on DBP providers compared with other similar provider groups. DBP providers spend a significant amount of time documenting progress notes both during and outside of normal clinic hours. This preliminary analysis highlights the utility of using EHR user activity data to quantitatively measure documentation burden.

Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: a Prospective Improvement Study.

The introduction of electronic workflows has allowed for the flow of raw un-contextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete of clinically significant "signals". There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating. To describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation. This is a multi-hospital nonrandomized prospective improvement study conducted on the Inpatient General Internal Medicine Service across three hospital campuses at the New York University (NYU) Langone Health System. A group of physician leaders representing each campus met biweekly for six months. The output of these meetings included 1) a conceptualization of the note bloat problem as a dysfunction in information flow 2) a set of guiding principles for organizational documentation improvement 3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations and 4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience measured using the System Usability Scale (SUS). Primary outcomes measures after go-live include template utilization rate and note length in characters. In usability testing amongst 22 medicine providers, the new progress note template averaged a usability score of 90.6/100 on the System Usability Scale. 77% of providers strongly agreed that the new template was easy to use. 68% strongly agreed that they would like to use the template frequently. In the three months after template implementation, General Internal Medicine providers wrote 65% of all inpatient notes with the new templates. During this period of time the organization saw a 46%, 47%, and 32% reduction in note length for general medicine progress notes, consults, and H&Ps, respectively, when compared to a baseline measurement period prior to interventions. A bundled intervention that included deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency and patient outcomes.

A hybrid system to understand the relations between assessments and plans in progress notes

Objective:The paper presents a novel solution to the 2022 National NLP Clinical Challenges (n2c2) Track 3, which aims to predict the relations between assessment and plan subsections in progress notes. Methods:Our approach goes beyond standard transformer models and incorporates external information such as medical ontology and order information to comprehend the semantics of progress notes. We fine-tuned transformers to understand the textual data and incorporated medical ontology concepts and their relationships to enhance the model’s accuracy. We also captured order information that regular transformers cannot by taking into account the position of the assessment and plan subsections in progress notes. Results:Our submission earned third place in the challenge phase with a macro-F1 score of 0.811. After refining our pipeline further, we achieved a macro-F1 of 0.826, outperforming the top-performing system during the challenge phase. Conclusion:Our approach, which combines fine-tuned transformers, medical ontology, and order information, outperformed other systems in predicting the relationships between assessment and plan subsections in progress notes. This highlights the importance of incorporating external information beyond textual data in natural language processing (NLP) tasks related to medical documentation. Our work could potentially improve the efficiency and accuracy of progress note analysis.

Correction to “Clinical progress note: Monkeypox infection among hospitalized patients”

Journal of Hospital MedicineEarly View CORRIGENDUMFree Access Correction to “Clinical progress note: Monkeypox infection among hospitalized patients” This article corrects the following: Clinical progress note: Mpox infection among hospitalized patients Ketino Kobaidze MD, PhD, Noble Maleque MD, Bashir Geer MD, Daniel Dressler MD, MSc, Volume 18Issue 2Journal of Hospital Medicine pages: 164-168 First Published online: December 9, 2022 First published: 28 March 2023 https://doi.org/10.1002/jhm.13091AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat The Journal's Editor-in-Chief has changed “Monkeypox” to “Mpox” in the title and throughout the text. The online version of this article1 has been corrected accordingly. REFERENCE 1Kobaidze K, Maleque N, Geer B, Dressler D. Clinical progress note: monkeypox infection among hospitalized patients. J Hosp Med. 2023; 18(2): 164- 168. doi:10.1002/jhm.13022 Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Clinical progress note: Evaluation and management of neonatal herpes simplex virus disease.

Clinical progress note: Evaluation and management of neonatal herpes simplex virus disease.

Methodological progress note: Machine learning methods in healthcare research.

Methodological progress note: Machine learning methods in healthcare research.

Clinical progress note: Revisions to the management of neonatal hyperbilirubinemia.

The authors declare no conflict of interest.

Evaluation of an electronic health record documentation tool use to improve pharmacist intervention tracking in the intensive care unit

AbstractPurposePharmacists are integral members of the healthcare team, but interventions are not always captured due to documentation limitations. This study evaluated the impact of implementing a tracking tool to address gaps in capturing pharmacist interventions.MethodsA prospective, observational study was conducted to assess pharmacist interventions between July and November 2020. Twelve critical care pharmacists captured interventions on 10 weekdays using a tracking tool (iVent—Epic®) embedded in the electronic medical record (EMR) to capture high frequency interventions not standardly captured via existing standard note documentation (e.g., renal/hepatic dose adjustment, parenteral nutrition management). Value added of the interventions is proposed. Patients' baseline demographics, interventions, Sequential Organ Failure Assessment (SOFA) score, and intensive care unit (ICU) length of stay (LOS) were collected. The primary outcome was to determine the added benefit of using a tracking tool within the EMR to capture pharmacist interventions compared to progress note documentation.ResultsTwo thousand seven hundred and eighty‐three interventions were documented on 514 unique patients over 120 pharmacist shifts. Of these, 2363 (84.9%) interventions were captured through iVent tracking. The median SOFA score on day of intervention was 4 [interquartile range (IQR) 2–7] and ICU LOS was 3.5 days [IQR 1.5–9]. The median number of interventions per patient per day was 2 [IQR 1–3]. A significant difference was observed among days of the week and the number of iVents documented (χ2 = 13.172, p = 0.01, df = 4). The post hoc pairwise comparison revealed more documented iVents on Tuesday than Friday.ConclusionThis study reveals that an iVent tracking tool increased total capture of pharmacist interventions by 563%. These interventions can be associated with value‐based programs and further work is needed in highlighting the pharmacist's role in these new payment models. This study confirms that the current standard practice at this institution of solely entering pharmacist progress notes into the patient chart misses a majority of pharmacist interventions.

Clinical progress note: Inpatient management of iron deficiency anemia.

Clinical progress note: Inpatient management of iron deficiency anemia.

1746. Electronic medical record-embedded clinical decision support decreases inappropriate duration of antibiotics for outpatient pediatric skin and soft tissue infections

Abstract Background Most antibiotics are prescribed outside of the hospital, and up to 50% are unnecessary or inappropriate. Studies of ambulatory stewardship interventions have primarily targeted respiratory infections. We investigated the impact of an electronic medical record (EMR)-embedded clinical decision support tool on antibiotic duration for outpatient pediatric skin and soft tissue infection (SSTI). Methods Institutional SSTI treatment guidelines for pediatric and adult patients were developed in 7/2019, followed in 5/2020 by dedicated education for primary care pediatricians. In 12/2020, a SmartSet (EMR-embedded tool with a templated progress note and antibiotic guidance) was created for pediatrics only. In this quasi-experimental pre-post study, we included adult and pediatric patients who were prescribed antibiotics for SSTI at a primary care or surgery clinic (in person, virtual, or phone) from 7/2019 to 12/2021. Inappropriate pediatric antibiotic duration ( >7 days) was compared pre- and post-intervention with interrupted time series (ITS) analysis of aggregate quarterly data. The trend in adult antibiotic duration was modeled with linear regression. Results We included 3,786 (948 pediatric and 2,838 adult) pre-intervention and 2,122 (469 pediatric and 1,653 adult) post-intervention visits. Pre-intervention, the percentage of inappropriate duration for pediatric patients was decreasing 1.6 percentage points per quarter (p < 0.01). After SmartSet implementation, there was an immediate decrease of 10.3 percentage points (p < 0.01), a relative decrease of 40% from the modeled percentage just prior to intervention (Figure 1). Inappropriate antibiotic duration for adults averaged 22.9% over the same period and did not change (p = 0.88). Figure 1Figure 1. Raw and modeled percentages of inappropriate antibiotic duration for skin and soft tissue infection before (quarters -6 to 0, encompassing Q3 2019 through Q4 2020) and after (quarters 0 to 4, encompassing Q1 2021 through Q4 2021) implementation of an EMR-embedded clinical decision support tool for pediatric patients. Time is represented in 3-month intervals, with quarter 0 being indicating the intervention at the end of December 2020. Conclusion Following guideline implementation and education, inappropriate antibiotic duration for ambulatory pediatric SSTI declined only modestly. An EMR-embedded clinical decision support tool was associated with an additional relative decrease of 40% in inappropriate antibiotic duration. In the same health system with comparable adult SSTI guidelines, the percentage of inappropriate antibiotic duration for adults was unchanged, suggesting timely EMR nudges can provide additional benefit over guidelines alone. Disclosures All Authors: No reported disclosures.

Social Risk Screening Changes Medical Decision-Making in a Complex Outpatient Pediatric Antibiotic Therapy Program.

Complex outpatient antibiotic therapy (COpAT) programs facilitate the treatment of serious infections at home, shorten inpatient stays, and improve patient satisfaction when compared to inpatient care [1]. However, COpAT delivery can be complicated by antibiotic side effects and vascular access problems, the management of which can become particularly difficult when attempted in the context of high social risk in the home and community [2]. The use of standardized social risk screening for optimizing infectious disease (ID) discharge plans is largely unexplored. We tested the feasibility and implementation of a novel social risk screening tool for COpAT and described alterations in care plans generated based on social risk information. A COpAT social risk screening tool was created by adapting publicly available social determinants of health screening toolkits [3, 4] to focus on social risks previously identified as prevalent in our patient population and relevant to our COpAT delivery system [5, 6] (Figure 1). From March to October 2019, the COpAT physician assistant assessed social risks for 29 of 40 (73%) consecutively eligible parents/caregivers. Results of social risk screening and COpAT modifications were documented in the patient’s EMR as a progress note. To assess changes made as a result of screening, we retrospectively compared the original COpAT plan by the inpatient consulting ID team to the final COpAT plan. We tabulated changes in COpAT plans using six predefined, a priori categories of change: (1) antibiotic use; (2) caregiver education; (3) COpAT follow-up plans; (4) social work referral; (5) new inpatient consultation; and (6) hospital length of stay. The study was deemed quality improvement and IRB oversight was waived.

Clinical progress note: Monkeypox infection among hospitalized patients.

Clinical progress note: Monkeypox infection among hospitalized patients.

Use of didactic training and feedback to improve quality and acceptability of progress notes written by direct‐care staff on a psychiatric inpatient unit

AbstractWriting progress notes represent a critical activity of practicing clinicians in a variety of settings. They provide a way for medical practitioners, insurance companies, and others to communicate in a timely fashion regarding ongoing clinical care. Previous research showed that intervention components like didactic training, using note templates, and feedback improved the quality of progress notes. At least two questions remain despite several studies already addressing progress note writing. First, previous research most often used multiple intervention components to improve progress notes. Thus, the relative impact of two common components of interventions, such as didactic training and feedback, is unclear. Second, previous research has not evaluated the acceptability of improved progress notes for the practitioners that actually utilize them. Thus, the purpose of the current study evaluated the components of didactic training and feedback on improved progress note writing for four direct staff employed by a psychiatric inpatient unit. A second purpose of this study was to evaluate the acceptability of the training procedures by both (a) the direct‐care staff participating in this study and (b) four members of the psychiatric treatment team that used direct‐care staff progress notes to inform their clinical care. Results showed that feedback was necessary to improve the accuracy of progress notes for three of four participants. The direct‐care staff reported the training procedures as acceptable and the treatment team noted improvements in the quality of the progress notes after intervention. These data will be discussed in terms of ways to arrange effective training programs to improve direct‐care staff's progress notes.

PSUN172 Prescribing SGLT-2 Inhibitors and GLP-1 Agonists in Primary Care: Improving Rates of Guideline-Concordant Practice

Abstract Background In practice, prescribing of a GLP-1 agonist (GLP-1a) or SGLT-2 inhibitor (SGLT-2i) for patients with type 2 diabetes mellitus (T2DM) and multiple risk factors for atherosclerotic cardiovascular disease (ASCVD) may be lagging behind the guidelines that recommend it. We aim to increase the prescribing rates of GLP-1as and SGLT-2is in a primary care resident clinic. Methods Eligible patients included adults with T2DM in an internal medicine primary care resident practice at the University of Vermont who were not already taking a SGLT-2i or GLP-1a. These patients were offered a diabetes medication management (DMM) visit with their PCP. The residents participated in a 30-minute educational intervention on: prescribing guidelines, medication risks and side effects, counseling patients, dose titration, and current Medicaid and Medicare insurance coverage estimates. This information was summarized in two tables that were included in a templated progress note to be used for DMM visits. DMM visits took place over a six month period. Chart review was conducted to determine patient co-morbidities and outcomes of the initial and follow-up DMM visits. Additional data was gathered from a post-visit survey completed by resident PCPs. Data was analyzed using descriptive methods. Results One hundred sixteen patients with T2DM were eligible. Sixty-five patients either declined, could not be reached, or did not present for their scheduled appointment. Fifty-one patients (44% of those eligible) completed a DMM visit. Of these 51, 18 (35%) were started on a SGLT-2i, either at the initial visit or at a follow-up visit. A GLP-1a was started for 14 (27%) patients. Nearly all who completed a DMM visit had at least one risk factor for ASCVD, and most had multiple risk factors. Problem lists for these patients showed that 40 (78%) had hypertension, 33 (65%) had hyperlipidemia, 12 (24%) had coronary artery disease, and 5 (10%) were current smokers. Two (4%) had a diagnosis of CHF, and 12 (24%) had CKD. Forty (out of 46) (87%) survey respondents reported that they were "more likely" to prescribe SGLT-2is and GLP-1as after participating in the intervention. The two most common reasons that these medications were not prescribed were the presence of competing visit priorities and co-management of diabetes medications by an endocrinologist. Conclusions Most patients with T2DM also have risk factors for ASCVD and would benefit from a GLP-1a or SGLT-2i. Prescriber education is an effective way to expand prescribing of these medications. Primary care providers are well-positioned to consider patients’ cardiovascular co-morbidities when prescribing diabetes medications, but may also be burdened by other visit priorities taking precedence. This study highlights the importance of a team-based approach to diabetes management and demonstrates a role for enhanced communication between primary care and specialties such as endocrinology and cardiology. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Clinical progress note: Life-threatening side effects of targeted therapies for solid tumors.

Sam Brondfield received consulting fees from American Physician Institute, Blackstone, Doximity, IDEO, and Pharmaceutical Associates Inc., and an honorarium from System Analytic. The remaining authors declare no conflict of interest.

Chart based data as a resource for tracking and improving a person-centred palliative approach in long-term care.

To enhance the practice of a person-centred palliative approach in long-term care. Implementing a person-centred palliative approach in long-term care entails placing residents at the centre of care planning that attends to the 'whole' person, rather than prioritising biomedical needs. We conducted a four-stage directed content analysis of long-term care progress notes to meet our study aims and applied the EQUATOR guidelines for qualitative research publication (COREQ). We qualitatively analysed 78 resident charts across three long-term care homes in southern Ontario to capture the extent to which person-centred care was absent, initiated or implemented in different types of documented care interactions. Most residents had interactions related to daily care activities (65/78, 83%), social concerns (65/78, 83%) and treatment decisions (53/78, 68%). By contrast, interactions around pain and discomfort (34/78, 44%) and spirituality (27/78, 35%) were documented for less than half of the residents. Almost all (92%) residents had at least one progress note where staff initiated person-centred care by documenting their preference for a certain type of care, but only a third had at least one progress note that suggested their preference was implemented (35%). While person-centred care is often initiated by nurses and other allied health professionals, changes to care plans to address resident preferences are implemented less often. Nurses and other allied health professionals should be encouraged to elicit care preferences crucial for holistic care planning and equipped with the skills and support to enact collaborative care planning. Collaborative care planning appears relatively absent in charted progress notes, constraining the full implementation of a person-centred palliative approach to care. An advisory group consisting of long-term care resident and staff representatives informed the overall study design and dissemination of the results.

Optimizing the patient handoff and progress note documentation efficiency in the EPIC EMR system within a neurosurgery residency: A quality improvement initiative

BackgroundHandoffs and documentation are a potentially modifiable source of medical error. However, little attention has been given toenhancementof these within the neurosurgical field. We aim to increase efficiency and accuracy of neurosurgical handoffs, including the neurological exam, thus decreasing medical documentation time within current duty-hour restrictions. MethodsThe existing Epic electronic medical record system was modified to include the neurological exam in the handoff: a tool used to generate lists including relevant patient clinical details and plans. The handoff tool was also converted into a subjective, objective, assessment, and plan (SOAP) format, which was leveraged to efficiently generate daily progress notes. A four-question survey was developed to assess the effectiveness of this new format. Mean note times were compared before and after the EPIC update using an independent samples t-test. ResultsAll of the surveyed neurosurgery residents at our institution reported a decrease in documentation time per progress note, felt the notes were more accurate, and found it easier to recall the neurological exams of patients. 8/9 residents felt that the new handoff made in-house call less stressful. There was a significant difference in mean note time, with the mean note time of 37.9 s after the EPIC upgrade compared to 120 s prior the upgrade. We project that over 241 h of documentation will be saved annually at our institution. ConclusionsThis QI project demonstrates how a low-effort initiative improved resident recall of patients’ neurological exams while saving time spent documenting daily progress notes.

Using Electronic Health Record Meta-Data to Identify Variation in Trainee Progress Note Writing Patterns: Opportunity to Enhance Systems-Based Care

Daily progress notes are the backbone of all inpatient hospitalizations. Progress notes serve as a lasting record of a patient's diagnoses, condition, and planned interventions and are essential communication tools. We designed a study to identify patterns in progress note filing and use on general surgical services. The electronic health record (EHR) data warehouse was queried for general surgical progress notes signed between July 1, 2020, and July 1, 2021. Only notes authored by resident physicians or advanced practice providers (APPs) were included, and those filed on the day of a surgery were excluded. 10 am was identified as a target for note completion as it coincided with multidisciplinary discharge rounds. Physician, case managers pharmacist, physical therapist, dietician, nurse (and collaborating disciplines) progress note views were measured using EHR access log data. A total of 8384 progress notes were analyzed; 4146 notes (49%) were authored by 81 trainees. A total of 4433 (53%) progress notes were filed before 10 am, 3673 (44%) were filed between 10 am and 6 pm, and 278 (3%) were filed after 6 pm. Variation in progress note file time was observed and associated with individual habits, residents vs APPs, day-of-week, and service structure. Surgery progress notes are viewed by collaborating disciplines throughout the workday, with high-volume viewership occurring by mid-morning. Each individual progress note received an average of 17.6 lifetime views with a range of 1 to 76. An average of 10.2 of those views occurred on the same day that the note was written. Notes that were filed after 10 am received a significantly lower number of same-day views compared to notes filed before 10am (8.4 vs 11.8, p < 0.0001). Progress notes are identified as a significant burden by trainees and even considered to contribute to duty hour violations, yet they are used regularly as a source of information for collaborating disciplines. Progress notes filed earlier are viewed more frequently. Efforts to identify barriers to timeliness may help communication and efficiency of inpatient surgical care.

Clinical progress note: Management of somatic symptomand related disorders in pediatric inpatients.

Clinical progress note: Management of somatic symptomand related disorders in pediatric inpatients.