SHM Converge Scientific Abstract ePoster Gallery-The Empty Smartlink Solution: A Qi Initiative to Improve H&p Documentation Using Clinical Decision Support

Pdf Summary

This quality improvement project aimed to reduce incomplete history and physical (H&P) documentation in Pediatric Hospital Medicine notes by using a clinical decision support (CDS) tool in Epic. The intervention added an empty SmartLink with a wildcard hard stop to the H&P template, prompting clinicians to address missing past medical, surgical, family history, or active hospital problem fields before signing.<br /><br />The team set a goal of reducing “no PMH/PSH/FH on file” and “no active hospital problems” documentation to under 5% within four months. They reviewed 1,129 patient encounters from March to June 2021 and used QI methods to track outcome, process, and balancing measures. Additional interventions included a housestaff meeting and an email reminder encouraging template use.<br /><br />Results showed improvement after the CDS tool was implemented. Special cause variation was observed, with rates decreasing to 1.2% for no PMH, 2.2% for no PSH, 2.9% for no FH, and 4.2% for no active hospital problems. The team surpassed its target. Importantly, use of the standardized PHM H&P template remained high at 87.2%, and reminder emails did not further increase usage. No negative balancing effects were noted, including no increase in free-texting family history as “none.”<br /><br />The authors concluded that a simple CDS intervention was associated with better H&P documentation and suggested expanding the tool to other areas of the hospital. Limitations included variable provider documentation habits, exclusion of some provider groups, and inability to assess whether the documented history was accurate.

Asset Subtitle

Sabrina E. Carro

Meta Tag

Author List Amanda J. Rogers, Danita Hahn, Sabrina E. Carro, Sarah Bauer, Sarah Milota

Category Research

Concept Clinical Decision Support

Concept Pediatric Hospital Use

Concept Electronic Health Record

Concept History Physical Template

Concept Past Medical History

Distinguished Non-Finalist

Presenter Organization Medical College of Wisconsin Affiliated Hosp.

Presenting Author Sabrina E. Carro

Track Quality Improvement

Keywords

Pediatric Hospital Medicine

history and physical documentation

clinical decision support

Epic EHR

quality improvement

SmartLink hard stop

template standardization

past medical history

family history

active hospital problems

Clinical Decision Support

Pediatric Hospital Use

Electronic Health Record

History Physical Template

Past Medical History