UCLA

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 included note template prompts for 4 of the diagnoses. Using a standardized rubric, we reviewed charts for 3 years (2013, 2014, and 2015). The average within-disease probability of missed high-risk diagnoses was compared across time.

Results

There was a decrease in the probability of undocumented target high-risk diagnoses after the intervention (52% vs 36% in 2014 [odds ratio = 0.51; P < .001] and 37% in 2015 [odds ratio = 0.50; P < .001]). Documentation of diagnoses prompted by the note template was not significantly better than those targeted by the other interventions alone (P = .55).

Conclusions

Pediatric residents were significantly less likely to omit a high-risk diagnosis in their notes after implementation of our documentation improvement program, suggesting that curriculum development is an effective method of improving documentation, with the goal of improving the accuracy of health systems performance indices.