J. C. Shahbandeh1, S. Liebscher1, C. Dekonenko1, B. Mohammadian1, J. A. Sullivan1, L. Selby1 1University Of Kansas, General Surgery, Lawrence, KS, USA
Introduction: Historically, general surgery residents at our institution have used a variety of note templates within the electronic medical record (EMR). These notes are routinely reviewed by coders to determine if documentation “accurately reflects all conditions that are being monitored, evaluated, or treated that extend the hospitalization or utilize additional resources of care”. When there is a possible discrepancy a coding query is issued. Addressing these queries takes between 5 and 15 minutes of dedicated resident chart review and additional documentation. We hypothesized that a standardized note template that proactively addresses common queries would allow residents to spend their time on direct patient care or in the OR.
Methods: We conducted a retrospective chart review of all queries sent to general surgery residents in the third quarter of 2020 to identify the most common conditions queried. We then developed a standardized note template that addressed these queries with directly imported EMR data and pre-programmed smartlists. The new note template was distributed to all residents at the beginning of the following academic year. Its use was voluntary. The percentage of queries issued for patients treated with each specific pathology during a 3-month period prior to standardization was then compared to the percentage issued during the same period a year later.
Results: In the first 3-month period of the 2020-2021 academic year we received 372 queries on a total of 2,309 patients (16.1% of all diagnoses queried). The most common queried conditions were malnutrition, renal failure, acidosis, electrolyte abnormalities, acidosis, wound/pressure ulcers, and obesity. After the development of the standardized note template, we treated 3,714 patients with the same diagnoses and received 385 queries (10.4% of all diagnosis queries) (p<0.01). The frequency of queries for pressure ulcers, acute blood loss anemia, acute renal failure, and anemia significantly decreased, the frequency of queries for acidosis increased, and the frequency of queries for malnutrition, chronic renal failure, or sepsis did not change (Table 1). Assuming 5 minutes/query, implementation of the standardized note was associated with saving each resident 43 minutes of work during the 3-month period.
Conclusion: Introducing a standardized note template was associated with a significant decrease in the number of documentation queries issued and significant resident time savings. Future work will focus on having more residents adopt the use of the new note template, improvement of the template itself, and further investigation of optimal ways to capture patient complexity within the EMR.
