An Educational Intervention to Improve Inpatient Documentation of High-risk Diagnoses by Pediatric Residents.

ABSTRACT:

Objectives

Diagnoses extracted from physician notes are used to calculate hospital quality metrics; failure to document high-risk diagnoses may lead to the appearance of worse-than-expected outcomes for complex patients. Academic hospitals often rely on documentation authored by trainees, yet residents receive little training in this regard. In this study, we evaluate inpatient pediatric resident notes to determine which high-risk diagnoses are commonly missed and assess the efficacy of a multitiered intervention to improve the documentation of these diagnoses.

Methods

In a baseline review of 220 charts, 13 frequently missed high-risk diagnoses were identified in 2013. Interventions began in 2014, including physician education and reference cards. The intervention also inclu

SUBMITTER: Kulkarni D 

PROVIDER: S-EPMC7080527 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature