Improving documentation of patient acuity level using a progress note template.

Grogan EL, Speroff T, Deppen SA, Roumie CL, Elasy TA, Dittus RS, Rosenbloom ST, Holzman MD
J Am Coll Surg. 2004 199 (3): 468-75

PMID: 15325618 · DOI:10.1016/j.jamcollsurg.2004.05.254

BACKGROUND - Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications.

STUDY DESIGN - Surgical residents and patients on three inpatient services were followed for a 1-year prospective cohort study. After a 6-month baseline period, a progress note template was developed and implemented for 6 months, and administrative data were retrieved. Residents were given three case examinations assessing documentation knowledge pre- and postintervention, and a satisfaction survey. Demographics, Charlson comorbidity score, ICD-9 codes, template-specific ICD-9 codes, All Patient Refined (APR)-DRG patient severity, DRG relative weight, predicted mortality (University Healthcare Consortium), pre- and postexam scores, and resident satisfaction were collected.

RESULTS - No difference in age, gender, race, or Charlson comorbidity score existed between pre- and postintervention patient groups. The length of stay decreased from 5.5 days to 4.8 days (p = 0.013). In the intervention group, total ICD-9 codes, template-specific ICD-9 codes, APR-DRG, DRG weight, and UHC predicted mortality had significant increases. Residents exposed to the progress note template improved their knowledge scores from 52% to 63% (p < 0.001), and 73% agreed that the progress note template was an improvement over handwritten notes. Residents not exposed to the progress note template did not improve their scores.

CONCLUSIONS - A progress note template improves documentation of comorbidities and complications, APR-DRG patient severity for benchmarking, and case-mix index, and increases patient-specific predicted mortality. The progress note template also improves surgical residents' documentation knowledge and satisfaction.

MeSH Terms (10)

Acute Disease Adult Benchmarking Comorbidity Documentation Forms and Records Control Humans International Classification of Diseases Medical Records Nursing Records

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