SHM Converge Scientific Abstract ePoster Gallery-Improving Rapid Response Documentation and Management Through a Note Template With Augmented Assessment and Plan

Pdf Summary

This project describes the creation of a new rapid response team (RRT) note template at the authors’ institution to improve documentation, communication, and billing during emergency events. Before January 2021, there was no standard RRT note template, and documentation was poor: only 18% of September 2020 RRT events had a provider note, and only 4% included critical care billing. The need was especially important because resident physicians often lead RRTs and may feel unprepared; in a survey, all internal medicine interns reported lack of confidence in leading RRTs, with medical knowledge as the main concern.<br /><br />To address this, the team built an Epic-based RRT note template with an augmented assessment and plan section. The template includes a SmartList of common diagnoses that, when selected through the dot phrase “.RRAP,” inserts a preformatted emergency-specific plan. Providers can use, edit, delete, or ignore these suggestions. The note also automatically prompts for critical care billing attestation for eligible providers and reminds authors to document family updates, patient disposition, and consultations.<br /><br />The goals were to encourage higher-quality documentation, provide management cues for novice providers, improve communication and patient outcomes, and increase critical care billing. After implementation, RRT documentation improved significantly by September 2021. The authors conclude that the template offers helpful structure and clinical guidance, especially for less experienced providers, and may support better care and more accurate billing. Future work will focus on education, reviewing template use and quality, and assessing effects on RRT management and patient outcomes.

Asset Subtitle

Alexandra C. Collis

Meta Tag

Author List Alexandra C. Collis, Angad Singh, Jesse A. Levin, Maralyssa Bann, Tiffany Chen

Category Innovations

Concept Rapid Response Note Template

Concept Rapid Response Team

Concept Note Quality

Concept Electronic Health Record

Concept Assessment and Plan Tool

Distinguished Non-Finalist

Presenter Organization University of Washington Medical Center

Presenting Author Alexandra C. Collis

Track Quality Improvement

Keywords

rapid response team

RRT note template

clinical documentation

Epic template

critical care billing

resident physicians

emergency events

SmartList

assessment and plan

patient outcomes

Rapid Response Note Template

Rapid Response Team

Note Quality

Electronic Health Record

Assessment and Plan Tool