SHM Converge Scientific Abstract ePoster Gallery-Changes in Documentation of the Principal Problem at Admission and Discharge in the Electronic Health Record: A Retrospective Descriptive Analysis

Changes in Documentation of the Principal Problem at Admission and Discharge in the Electronic Health Record: A Retrospective Descriptive Analysis

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This retrospective study examined how the “hospital principal problem” (HPP) was documented in the electronic health record for all general medicine admissions at a large academic medical center in Boston during 2019. The goal was to see whether the admission diagnosis recorded in the problem list changed by discharge and what those changes meant.<br /><br />Among 6,635 admissions, 5,527 (83.3%) had an HPP entered at admission. Most admission HPPs were etiologic diagnoses rather than vague symptom-based labels. Only 331 admissions (5%) showed any change in the HPP from admission to discharge.<br /><br />The researchers reviewed cases where an undifferentiated diagnosis changed to an etiologic diagnosis, and a sample of cases where it changed to a different undifferentiated diagnosis. The most common reason for a change from an undifferentiated to an etiologic diagnosis was that diagnostic testing identified a more specific cause during hospitalization (85.3% of sampled cases). Examples included moving from “dyspnea” to “aortic stenosis.” In a smaller share of cases, the diagnosis changed because the problem had already been known but was clarified during the stay.<br /><br />For changes from one undifferentiated diagnosis to another, the most common explanation was suboptimal documentation rather than a true change in clinical reasoning. Some entries remained symptom-based even when a more specific diagnosis was available.<br /><br />Documentation was mainly entered by trainee physicians (64%), followed by non-trainee physicians (25.6%) and advanced practice providers (9.8%).<br /><br />Overall, the study found that HPP documentation was often not updated to reflect evolving diagnostic reasoning. The authors suggest quality improvement efforts, education, and possibly natural language processing tools to help keep the problem list accurate.

Asset Subtitle

Daniel Motta-Calderon

Meta Tag

Author List Alison Garber, Alyssa Lam, Anuj K. Dalal, Daniel Motta-Calderon, David W. Bates, Jeffrey L. Schnipper, Kevin Carr, Kumiko Schnock, Maria Malik

Category Research

Concept Principal Problem

Concept Working Diagnosis

Concept Admission Diagnosis

Concept Discharge Diagnosis

Concept Electronic Health Record

Distinguished Non-Finalist

Presenter Organization Vanderbilt University Medical Center

Presenting Author Daniel Motta-Calderon

Track Patient Safety

Keywords

hospital principal problem

electronic health record

problem list documentation

general medicine admissions

retrospective study

admission diagnosis

diagnostic reasoning

etiologic diagnosis

undifferentiated diagnosis

quality improvement

Principal Problem

Working Diagnosis

Admission Diagnosis

Discharge Diagnosis

Electronic Health Record