Strategies for improving physician documentation in the emergency department: a systematic review
Abstract Background Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documen...
| Main Authors: | , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2018-10-01
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| Series: | BMC Emergency Medicine |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s12873-018-0188-z |
| _version_ | 1818276911706537984 |
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| author | Diane L. Lorenzetti Hude Quan Kelsey Lucyk Ceara Cunningham Deirdre Hennessy Jason Jiang Cynthia A. Beck |
| author_facet | Diane L. Lorenzetti Hude Quan Kelsey Lucyk Ceara Cunningham Deirdre Hennessy Jason Jiang Cynthia A. Beck |
| author_sort | Diane L. Lorenzetti |
| collection | DOAJ |
| description | Abstract Background Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown. Methods We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation. Results Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results. Conclusions Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation. |
| first_indexed | 2024-12-12T22:53:10Z |
| format | Article |
| id | doaj.art-0d0b5b2d2e244088b2488f23eeb0af38 |
| institution | Directory Open Access Journal |
| issn | 1471-227X |
| language | English |
| last_indexed | 2024-12-12T22:53:10Z |
| publishDate | 2018-10-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Emergency Medicine |
| spelling | doaj.art-0d0b5b2d2e244088b2488f23eeb0af382022-12-22T00:09:00ZengBMCBMC Emergency Medicine1471-227X2018-10-0118111210.1186/s12873-018-0188-zStrategies for improving physician documentation in the emergency department: a systematic reviewDiane L. Lorenzetti0Hude Quan1Kelsey Lucyk2Ceara Cunningham3Deirdre Hennessy4Jason Jiang5Cynthia A. Beck6Department of Community Health Sciences, Cumming School of Medicine, University of CalgaryDepartment of Community Health Sciences, Cumming School of Medicine, University of CalgaryDepartment of Community Health Sciences, Cumming School of Medicine, University of CalgaryDepartment of Community Health Sciences, Cumming School of Medicine, University of CalgaryDepartment of Community Health Sciences, Cumming School of Medicine, University of CalgaryDepartment of Community Health Sciences, Cumming School of Medicine, University of CalgaryDepartment of Psychiatry, Cumming School of Medicine, University of CalgaryAbstract Background Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown. Methods We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation. Results Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results. Conclusions Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.http://link.springer.com/article/10.1186/s12873-018-0188-zDocumentationEmergency departmentsMedical recordsPhysiciansSystematic reviews |
| spellingShingle | Diane L. Lorenzetti Hude Quan Kelsey Lucyk Ceara Cunningham Deirdre Hennessy Jason Jiang Cynthia A. Beck Strategies for improving physician documentation in the emergency department: a systematic review BMC Emergency Medicine Documentation Emergency departments Medical records Physicians Systematic reviews |
| title | Strategies for improving physician documentation in the emergency department: a systematic review |
| title_full | Strategies for improving physician documentation in the emergency department: a systematic review |
| title_fullStr | Strategies for improving physician documentation in the emergency department: a systematic review |
| title_full_unstemmed | Strategies for improving physician documentation in the emergency department: a systematic review |
| title_short | Strategies for improving physician documentation in the emergency department: a systematic review |
| title_sort | strategies for improving physician documentation in the emergency department a systematic review |
| topic | Documentation Emergency departments Medical records Physicians Systematic reviews |
| url | http://link.springer.com/article/10.1186/s12873-018-0188-z |
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