Hospitalist physicians rely on admission history and physicals and daily progress notes as important tools for communication regarding patient care and compliance with billing and coding requirements. While electronic health records facilitate ease of thorough documentation, many physicians raise concerns regarding documentation accuracy and readability.
We aim to improve note accuracy, readability, and billing and coding compliance while preserving ease of documentation through the establishment of uniform documentation practices among providers within an academic medical center division of hospital medicine.
A baseline survey of division members (66% response rate; n= 33) revealed an overwhelming majority were satisfied with the ease and time required for documentation. While 88% of physicians were satisfied with the readability and accuracy of their own documentation, only 47% and 33% of respondents were satisfied with the readability and accuracy, respectively, of their peers’ documentation. Only 40% of physicians were at least very confident that their notes met compliance standards for the level billed. Applying expert recommendations, our documentation task force used a deliberate design process to develop novel history and physical and progress note templates incorporating auto‐population of key components, with forced prompts for information not appropriate for auto‐population. The templates were designed to be easily readable, with the assessment and plan placed prominently at the beginning. Additionally, pre‐populated, editable elements such as a default physical exam were designed to optimize billing and coding compliance. The intervention included education and facilitated discussion on documentation best practices and the note templates. We instituted a separate educational initiative on individual and group billing practices simultaneously. Two months after implementing the templates and educational initiatives we administered a follow‐up survey to assess improvement (54% response rate; n=27). Results of a series of independent means t‐tests comparing baseline and post‐intervention surveys showed statistically significant improvements in provider satisfaction with the accuracy of their own progress notes as well as the accuracy and readability of their peers’ progress notes, with mean improvements of .33, .65 and .86 respectively on a 5 point scale (p<0.05). We preserved satisfaction with ease of documentation but found no improvement in confidence of billing and coding compliance.
Through provider education and the application of information technology tools, we can improve documentation accuracy and readability while preserving efficiency. Future plans for this project include development of a peer review process and facilitation of a similar initiative among internal medicine residents. We continue to engage in initiatives to improve physician confidence with billing and coding.
To cite this abstract:Allen J, Knight J, Patel C, Shaw S, Walker C, Lewis K. Battling ‘Note Bloat’: An Intervention to Improve Electronic Documentation Accuracy, Readability, and Compliance, While Preserving Provider Efficiency. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 210. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/battling-note-bloat-an-intervention-to-improve-electronic-documentation-accuracy-readability-and-compliance-while-preserving-provider-efficiency/. Accessed April 1, 2020.