An automated procedure logging system improves resident documentation compliance. 2011

Thomas S Seufert, and Patricia M Mitchell, and Allison R Wilcox, and Julia E Rubin-Smith, and Laura F White, and Kerry K McCabe, and Jeffrey I Schneider
Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA. jeffrey.schneider@bmc.org

OBJECTIVE The purpose of this study was to determine the effect of an automated procedure logging (APL) system on the number of procedures logged by emergency medicine (EM) residents. Secondary objectives were to assess the APL's effect on completeness and accuracy of procedure logging and to measure resident compliance with the system. METHODS This was a before-and-after study conducted at a university-affiliated, urban medical center, with an annual emergency department census of >130,000. The EM residency is a 4-year, Residency Review Committee (RRC)-accredited program with 12 residents per year. We developed software to electronically search and abstract resident procedures documented in the electronic medical record (EMR) and automatically export them into a Web-based residency management system. We compared the mean daily number of procedures logged for two 6-month periods: October 1, 2009, to March 31, 2010 (pre-APL), and October 1, 2010, to March 31, 2011 (post-APL), using a two-sample t-test. We also generated a random sample of 231 logged procedures from both the pre- and post-APL time periods to assess for completeness and accuracy of data transfer. Completeness and accuracy in the pre- and post-APL periods were compared using Fisher's exact test. Aggregate resident compliance with the system was also measured. RESULTS The mean daily number of procedures logged increased by 168% (10.0 vs. 26.8, mean difference = 16.8, 95% confidence interval [CI] = 15.4 to 18.2, p < 0.001) after the implementation of APL. Procedures logged with the APL system were more complete (76% vs. 100%, p < 0.001) and more accurate (87% vs. 99%, p < 0.001). Most residents (42/48, 88%) used APL to log at least 90% of procedures. Only 4% of procedures eligible for automation were logged manually in the post-APL period. CONCLUSIONS There was a significant increase in the daily mean number of procedures logged after the implementation of APL. Recorded data were more complete and more accurate during this time frame. This innovative system improved resident logging of required procedures and helped our assessment of Accreditation Council for Graduate Medical Education (ACGME) Patient Care and Practice-Based Learning Competencies for individual residents.

UI MeSH Term Description Entries
D007396 Internship and Residency Programs of EDUCATION, MEDICAL, GRADUATE training to meet the requirements established by accrediting authorities. House Staff,Internship, Dental,Residency, Dental,Residency, Medical,Dental Internship,Dental Internships,Dental Residencies,Dental Residency,Internship,Internship, Medical,Internships, Dental,Medical Residencies,Medical Residency,Residencies, Dental,Residencies, Medical,Residency,Residency and Internship,Internships, Medical,Medical Internship,Medical Internships,Residencies,Staff, House
D008297 Male Males
D010818 Practice Patterns, Physicians' Patterns of practice related to diagnosis and treatment as especially influenced by cost of the service requested and provided. Clinical Practice Patterns,Physician's Practice Patterns,Clinical Practice Pattern,Pattern, Clinical Practice,Patterns, Clinical Practice,Practice Pattern, Clinical,Practice Patterns, Clinical,Practice Patterns, Physician's,Prescribing Patterns, Physician,Physician Practice Patterns,Physician Prescribing Pattern,Physician Prescribing Patterns,Physician's Practice Pattern,Physicians' Practice Pattern,Physicians' Practice Patterns,Practice Pattern, Physician's,Practice Pattern, Physicians',Practice Patterns, Physician,Prescribing Pattern, Physician
D001900 Boston City located in Massachusetts.
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D004635 Emergency Medicine The branch of medicine concerned with the evaluation and initial treatment of urgent and emergent medical problems, such as those caused by accidents, trauma, sudden illness, poisoning, or disasters. Emergency medical care can be provided at the hospital or at sites outside the medical facility. Medicine, Emergency
D004638 Emergency Treatment First aid or other immediate intervention for accidents or medical conditions requiring immediate care and treatment before definitive medical and surgical management can be procured. Emergency Therapy,Therapy, Emergency,Emergency Therapies,Emergency Treatments,Therapies, Emergency,Treatment, Emergency,Treatments, Emergency
D005260 Female Females
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D001331 Automation Controlled operation of an apparatus, process, or system by mechanical or electronic devices that take the place of human organs of observation, effort, and decision. (From Webster's Collegiate Dictionary, 1993) Automations

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