SHM Converge Scientific Abstract ePoster Gallery-Standardizing Documentation Templates: Evaluating Efficiency, Billing Accuracy, and Clinical Documentation in a Hospital Setting

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This study evaluated whether standardizing EMR note templates for hospital medicine teams improved efficiency, billing-related documentation, and patient outcomes at an academic medical center.<br /><br />Between August 2023 and July 2025, there were 19,765 inpatient encounters. Patients had an average age of 62 years, with the cohort being 55% Hispanic, 26% Black, and 71% White. Standardized templates were introduced in July 2024, and the analysis compared several operational periods: no template use, template use with Elixhauser comorbidity index removal, Elixhauser reintroduction, and later implementation of an automated CDI documentation workflow.<br /><br />The study examined CDI query volume, length of stay (LOS), mortality, 30-day readmission, CAUTI/CLABSI rates, documentation time, and financial metrics such as RVUs, charges, and payments. Statistical analysis used descriptive methods and linear regression.<br /><br />Key findings showed that LOS decreased significantly from 7.31 to 6.74 days, and observed/expected LOS fell from 1.14 to 0.92. CDI queries also decreased after the CDI workflow was implemented in June 2025, from 18 to 13 queries per day. There were no differences in 30-day readmission or mortality, suggesting no harm to patient safety outcomes. Daily EMR activity increased from 368 to 409 minutes per day, indicating an additional 41 minutes of documentation time. RVUs improved after reimplementation of the Elixhauser comorbidity index.<br /><br />Overall, standardized documentation templates appeared to reduce CDI burden and LOS without worsening quality or safety outcomes. However, the increase in documentation time suggests a possible added workload for providers, even if documentation quality improved.

Asset Subtitle

Jennifer Concepcion

Meta Tag

Author List Andrew Para, Chad Flowers, Daniel Del Castillo Rix, Darius Chyou, Jennifer Concepcion, Marcio Soares, Sebastian Suarez

Category Research

Concept Electronic Medical Record Template

Concept Documentation efficiency

Concept Provider Documentation Time

Concept Documentation Quality

Concept Clinical Documentation Integrity Query Burden

Distinguished Non-Finalist

Presenter Organization University of Miami Miller School of Medicine

Presenting Author Jennifer Concepcion

Track Quality Improvement

Keywords

EMR note templates

hospital medicine

documentation standardization

clinical documentation improvement

length of stay

CDI queries

Elixhauser comorbidity index

documentation time

readmission rates

patient outcomes

Electronic Medical Record Template

Documentation efficiency

Provider Documentation Time

Documentation Quality

Clinical Documentation Integrity Query Burden