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Description

Abstract: As inpatient care has grown in complexity and front-line clinicians (FLCs) must create and update a larger volume of information, inefficient and fragmented documentation systems put hospitalized patients at risk of harm from communication errors. In addition to writing and updating admission notes, progress notes, and discharge summaries, FLCs must also update plans of care and problem lists in their handoffs – often independently. Further, the information therein is generally locked in free-text, which cannot be easily reused for clinical decision support. With this duplicative workflow, FLCs struggle to maintain high quality notes and handoffs, and discrepancies between information documented between the two are known to occur. Problem-oriented documentation tools from electronic health record vendors have begun to address these issues by mandating coded problem names and allowing users to specify a block of information as historical. However, these tools lack the granularity required to optimize task management and handoffs. In this didactic panel, we will review the successes and failures of structured and flexible documentation systems, describe strengths and weaknesses of a vendor approach to problem-oriented documentation, and discuss novel models that organize clinical reasoning documentation into discrete elements that can be reused to improve clinical workflow.

Learning Objective 1: Understand how the inpatient care plan is distributed across multiple documents and how data can be re-used to improve workflow and avoid inconsistencies.

Learning Objective 2: Review the successes and failures of structured and flexible documentation systems.

Learning Objective 3: Describe the strengths and shortcomings of vendor-based tools to address these problems.

Learning Objective 4: Discuss new approaches to documentation that structure impressions and plans into a data model that can be filtered into workflow tools optimized for provider role and context.

Authors:

Mark Mai (Presenter)
Children's Hospital of Philadelphia

Kai Zheng (Presenter)
University of California, Irvine

Eric Shelov (Presenter)
Children's Hospital of Philadelphia

Subha Airan-Javia (Presenter)
University of Pennsylvania Health System

Evan Orenstein (Presenter)
Children's Hospital of Philadelphia

Presentation Materials:

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