EHR templates improve documentation of resident procedures, supervision

Discrete template notes in an electronic health record can be used to monitor both the procedures performed by medical residents and the supervision of these procedures, according to new research published online in the Journal of the American Medical Informatics Association (JAMIA).

Medical residents must be able to competently perform medical, diagnostic and surgical procedures. At the same time, they must be supervised, and that supervision must be monitored. This is often conducted by manual abstraction of medical records, surveys, interviews, or through the use of personal procedure logs, all of which require more time and energy, and may not be very precise.

The researchers, from the University of Texas Southwestern Medical Center in Dallas and elsewhere, created a semi-automatic system to capture information at Parkland Memorial Hospital, using NoteWriter in its EpicCare inpatient EHR. They developed templates for common specific procedures, as well as a generic one, so every procedure outside of formal procedure areas could be documented. Every template also captured whether a resident had direct or indirect supervision, who their supervisor was, and whether prior discussion of the procedure with an attending occurred.

More than 27,000 procedures by 1,075 residents were recorded between August 2012 and June 2014. The system also created automated reports so that compliance could be monitored. As time went on, the hospital encouraged compliance by adding the use of follow-up letters and hard stops for users to complete mandatory fields.

When the project began, only 12.5 percent of residents documented supervision. By the end of the first year, more than 80 percent were doing so. Compliance averaged 74.8 percent in the first three months, and increased to 94.6 percent in the second year.

"With this [system], we can ensure that appropriate levels of supervision are being documented, captured, and proceed in real time to allow for institution-wide monitoring, reporting and action based on the data where indicated," the researchers said. "This potentially enhances resident education and affords the opportunity to impact patient safety by ensuring oversight."

To learn more:
- here's the abstract