SHM Converge Scientific Abstract ePoster Gallery-Implementing Standardized Automatic Note Templates Improves Documentation Integrity and Efficiency

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This project evaluated whether a standardized, automated note template could improve documentation quality and efficiency on general medicine teaching services at the University of Wisconsin–Madison.<br /><br />The intervention, implemented on 06/01/2021, included automatic forwarding of the assessment/plan, a physical exam Smart Phrase, and integrated help text to guide charting. The team compared pre- and post-implementation Epic data, including Clinical Documentation Integrity (CDI) queries, diagnosis coding, complication/comorbidity capture rates, and Elixhauser comorbidities. They also surveyed residents about whether the template saved time and improved attendance at noon conferences and signout. In addition, a “safety rounding checklist” was added on 10/10/2022 to improve documentation of DVT prophylaxis, code status, nutrition, and PT/OT orders, with manual chart review used to assess agreement between orders and documentation.<br /><br />Results showed that the template improved documentation integrity and efficiency. It increased diagnosis codes, CC/MCC capture rates, and Elixhauser comorbidity documentation while reducing CDI queries. Resident feedback indicated high satisfaction, with agreement that the template saved time, improved ability to attend mid-day conferences, and supported more timely signout. The safety checklist also produced major improvements in congruency between documented and ordered items, especially DVT prophylaxis and diet/PT/OT-related orders.<br /><br />Overall, the standardized note template was effective and well received. The authors conclude that further work should examine downstream clinical outcomes such as DVT rates, major bleeding, and length of stay, and that continued resident involvement will be important for future improvement.

Asset Subtitle

Kevin Titus

Meta Tag

Author List Jordan Kenik, Kevin Titus, Sean O'Neill

Category Research

Concept Clinical Documentation Integrity

Concept Templated Note

Concept Electronic Health Record

Concept CDI Query

Concept Documentation Quality

Distinguished Non-Finalist

Presenter Organization University of Wisconsin Hospital and Clinics

Presenting Author Kevin Titus

Track Quality Improvement

Keywords

standardized note template

documentation quality

efficiency

general medicine teaching services

Epic data

Clinical Documentation Integrity

diagnosis coding

Elixhauser comorbidities

resident satisfaction

safety rounding checklist

Clinical Documentation Integrity

Templated Note

Electronic Health Record

CDI Query

Documentation Quality