SHM Converge Scientific Abstract ePoster Gallery-Implementation of a Standardized Admission Note to Improve Measurement of Diagnoses and Estimation of Expected Mortality

Implementation of a Standardized Admission Note to Improve Measurement of Diagnoses and Estimation of Expected Mortality

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The project addressed under-documentation of chronic and low-acuity comorbidities in admission history and physical (H&P) notes, which was causing expected mortality (EM) to be underestimated at Duke. Providers had been free to use any H&P template, and important conditions such as malnutrition, electrolyte deficiencies, anemia, and coagulopathy were often missed because they were not a documentation priority.<br /><br />The team aimed to improve EM estimation without increasing clinician workload. They implemented a standardized admission H&P template as the default for General Medicine admissions. In the first PDSA cycle, the template included static reminders to document commonly overlooked comorbidities. In the second cycle, they added a Clinical Documentation Integrity (CDI) “SmartBlock” that automatically reviewed discrete data from the previous 24 hours and inserted relevant diagnoses into the note.<br /><br />Results showed improved capture of selected comorbidities after template implementation. EM increased from 2.4% to 3.51%, and the mortality index decreased from 1.05 to 0.73. When the CDI tool was used, patients had a higher EM and lower mortality index than when it was not used (3.75% vs 3.25% EM; 0.69 vs 0.79 MI). The template was widely adopted, used in 87% of admissions, and did not increase perceived documentation time or disrupt workflow.<br /><br />Overall, a standardized admission note with automated diagnosis prompts improved documentation of missed comorbidities and led to better mortality risk estimation, with potential for further refinement to capture additional under-documented conditions.

Asset Subtitle

Noppon P. Setji

Meta Tag

Author List Brian Griffith, Fletcher Fair, James Howard, Lana Wahid, Michael Burt, Noppon P. Setji, Puneet Singh, Robert Musser, Sheila S. Sherzoy, Talia Bernal, Tara Spector, Yvonne Acker

Category Innovations

Distinguished Non-Finalist

Presenter Organization Duke University Hospital

Presenting Author Noppon P. Setji

Track Quality Improvement

Keywords

chronic comorbidities