Influence of structured encounter forms on documentation by community pediatricians.

ABSTRACT

Background. Age-specific structured encounter forms for well-child examinations have been shown to improve thoroughness of documentation among pediatric house staff. This study evaluated the influence of such forms on completeness of documentation by practicing pediatricians.

Methods. In this before-after trial at 5 urban community health clinics, participants were 8 pediatricians practicing for at least 1 year. Brief group training sessions on use of the forms were provided to the participating physicians. Completeness of documentation was defined as the proportion of elements from a full well-child examination recorded in the medical record.

Results. After introduction of the standardized forms, completeness of documentation significantly increased for all components.

Conclusions. The use of age-specific structured encounter forms improved the completeness of documentation of pediatric well-child examinations done by pediatricians.

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THE MEDICAL RECORD is increasingly read by a variety of external reviewers. Incomplete, inaccurate, or unclear documentation is subject to different interpretation by each of these readers. Whether used as proof of services rendered for third-party reimbursement, proof of compliance with managed care requirements, evidence in a malpractice case, or as data for clinical research and quality review, the accuracy and completeness of documentation in the medical record can have profound implications for both patient and physician. (1-4) Studies focusing on quality assurance have addressed improving the quality of documentation in clinical practice. (5-7)

Concerns have been raised about the quality of medical documentation in ambulatory pediatrics, chiefly as the result of difficult or failed attempts to abstract data from medical records for clinical research and quality assessment. (2,4) Duggan et al (2) noted that widespread incomplete and inaccurate documentation of pediatric ambulatory care visits prohibited the 1975 Joint Commission on Quality Assurance of the American Academy of Pediatrics from completing a review of chart audit techniques to evaluate ambulatory pediatric care. In response to these concerns, efforts to improve the quality of documentation, facilitate quality and continuity of care, and improve the data available from chart reviews have stimulated interest in the use of standardized encounter forms in the ambulatory care setting. (1-4) Ambulatory pediatrics, in particular, is well suited for standardized record keeping because of its high patient volume and necessity for repeated screening procedures. (1)

Duggan et al (2) noted an improvement in completeness of documentation among house staff in an urban teaching hospital pediatric primary care clinic among those choosing structured encounter forms versus those using free text. (2) Furthermore, a pediatric house staff continuity clinic study compared varying the content of structured encounter forms on resident knowledge, parent satisfaction, and compliance with guidelines for age-specific health supervision visits. Improvement in resident knowledge and / or parent satisfaction was greater in the areas of either anticipatory guidance or developmental milestones that were emphasized on the forms. (3) In addition, a trial in a university-affiliated emergency department showed that the use of structured complaint-specific encounter forms by both residents and attending faculty resulted in improved documentation, changes in clinical practice, and decreased test use when compared with free text record keeping. (4) Standardized well-child encounter forms were found to improve the documentation of preventive pediatric services when compared with free text documentation in a community health program study. (8) Finally, standardized encounter forms were evaluated in a family practice resident clinic and were found to improve almost all aspects of documentation emphasized on the forms, with less of an increase in preventive screening tests. (9)

Although these previous reports have addressed the influence of structured forms on the quality of documentation in clinical practice, they have been limited in their evaluation to purpose-specific forms designed for resident physicians practicing at an urban teaching hospital. Community clinics and physician offices are increasingly used as training sites for residents and represent a more typical private practice environment, yet the impact of forms on the practicing pediatrician has not been reported. The primary aim of this study was to evaluate the influence of introducing broadly applicable, age-specific, standardized encounter forms on the completeness of documentation for well-child examinations conducted by practicing pediatricians in five urban community health clinics.

METHODS

Procedures

After obtaining institutional review board approval from the University of Miami School of Medicine, potential participants were identified through a local managed care continuing medical education (CME) program. Of 9 pediatricians participating in the program, 8 were eligible for the study as a currently practicing physician with residency training in pediatrics. The number of years in practice ranged from 1 to 22 years. Of the 8 physicians eligible to participate, all agreed to take part in the study.

The 8 participants practiced at 5 urban community health clinics in Dade County, Miami, Florida. Before the study, 4 of the clinics used a brief checklist of developmental questions, and 1 clinic had already been using the study forms (Tots-to-Teens) for approximately 1 year. All other documentation for the medical record was made in free text on lined paper.

Standardized, age-specific encounter forms were introduced to participants and their associated staff through a 15-minute slide show explaining the components of the forms. Although the participants could not be blinded to use of the forms, they were blinded to the outcome measure and the specific hypothesis under investigation. Each participant was provided with Tots-to-Teens forms and was asked to use the forms for all well-child visits during the study period.

Measurements

The Appendix contains a sample of the age-specific structured encounter forms under evaluation (Tots-to-Teens forms), created by the principal investigator (P.G.). The forms contain age-appropriate prompts for comprehensive well-child examinations and are based on the American Academy of Pediatrics guidelines (10) for well-child care. Since their creation, they have been revised four times in response to peer review by the faculty of the University of Miami; this study used the final revision form only.

An examination was considered eligible for review if it was for a well-child health supervision visit conducted by a participating pediatrician for a patient aged 1 month to 5 years at the time of examination. For each of the 8 participants, one examination was abstracted for each of 12 age-specific recommended health-supervision visits for the periods before and after introduction of the forms (n = 192). The first record identified that matched the criteria of age and well-child examination was abstracted without correlation to number of times the form had been used by that physician. The actual forms completed by the physician were abstracted directly from the child's medical record.

Completeness of documentation was defined as the proportion of elements of a full well-child examination recorded in the medical record. An examination was considered 100% complete if all elements included on the age-specific Tots-to-Teens form were included in the medical record. The elements were based on the American Academy of Pediatrics Guidelines for Health Supervision II. (7) The quality of a particular element of the examination was not recorded; only the presence or absence of documentation that the element had been done was recorded. Completeness of documentation was calculated for the entire examination and separately for each subdomain of the health supervision visit: Growth & Development, Physical Examination, Anticipatory Guidance, Health Counseling, Nutrition Counseling, Safety Counseling, and Psychosocial/Behavioral Counseling. One of us who was not blinded to the study hypothesis (H.S.) abstracted the data.

Statistical Methods

One-factor analysis of variance was used to determine whether differences in completeness of documentation among participating physicians existed before introduction of the forms. Mean documentation measures were compared for the examination as a whole and then separately for each major subcomponent. Two-factor analysis of variance was used to compare completeness of documentation before and after introduction of the forms among and between participants. Comparisons were made for completeness of documentation for the forms as a whole and separately for each major examination subdomain.

RESULTS

We reviewed 192 patient well-child care visits documented on the age-appropriate Tots-to-Teens form completed by eight physicians. Before introduction of the forms, the group mean for overall completeness of documentation was 35.4% items documented (SD 1.3). After introduction of the forms, the group mean for overall completeness of documentation increased significantly to 77.6% items documented (SD 1.5; P< .0001). A similarly significant increase after introduction of the forms was apparent in the documentation of each major subdomain of the examination. The greatest increases were in Anticipatory Guidance (7.8% before, 58.6% after; P < .0001) and Safety Counseling (30.2% before, 73.4% after; P < .0001). The smallest increases were observed for documentation of the Physical Examination (65.4% before, 94.6% after; P < .0001) and Nutrition Counseling (45.7% before, 76.4% after; P < .0001) (Table). Although the magnitude of change was different, improvements in completeness of documentation were significant for all participants.

The average increase in overall completeness of documentation was 42.2% (SE 3.8) for all physicians. A significant difference in overall levels of completeness of documentation between physicians was found both before and after the introduction of the forms. When stratified by examination subcomponent, significant differences (P < .05) in documentation before introduction of the forms remained for all subcomponents except Psychosocial Counseling and Health Counseling. After introduction of the forms, significant differences in documentation between the participating pediatricians were observed for all subcomponents except the Physical Examination. No individual physician was significantly higher or lower than the whole group in completeness of documentation for more than three examination subdomains either before or after use of the forms.

DISCUSSION

This study showed that the introduction of age-specific structured encounter forms resulted in a marked improvement in the completeness of the documentation of well-child examinations done by pediatricians in urban community health clinics. Overall, completeness of documentation increased from 35.4% before introduction of the forms to 77.6% when the forms were used (P < .0001). Although the magnitude of change was different for each participant, completeness of documentation increased for every physician when using the forms (P< .0001).

When interpreting the results of this study, it is important to consider its limitations. Participants could not be blinded to the type of form they were using to document well-child examinations. Knowledge that the study included a review of medical records may have led participants to use greater care in documenting examinations than would have been observed if they had not been aware of the medical record review (ie, the Hawthorne effect).

Although the number of medical records reviewed was sufficient to provide stable estimates of the completeness of documentation for a before-after comparison, the study's small number of participants had limited power to make comparisons between participants or to adjust for covariates related to individual participant differences. With a larger number of participants, analyses of changes in clinical practice (patient flow, patient contact time, physician satisfaction) after introduction of forms could also be made. The small sample size also did not allow for accounting for duration of exposure to the forms. Further research is needed to assess whether documentation improves as physicians become more comfortable with the format or whether they tend to ignore the prompts as they become accustomed to them.

A final concern with the interpretation of these results lies in the inference that may be drawn from an increase in completeness of documentation. The question of whether what was documented in the medical record is an accurate representation of what transpired in the examination must be addressed. Indeed, inaccuracy through overdocumentation, resulting from careless marking of a list of check-off boxes, is as great a concern as not documenting something that was actually done. Although a natural tendency to under-document examinations using free text and to overdocument using forms with check-off boxes was noted on some examinations, the two studies of documentation that have included a direct observation or tape recorded component showed good agreement between what was written in the record and what was done in the examination room. (2,3) For direct inferences between documentation and quality of care to be drawn, validation of documentation through direct observation of examinations would be imperative.

CONCLUSION

Our study supports previous studies showing the benefit of standardized forms on documentation. However, it is unique in its focus on the practicing pediatrician. With improved documentation, it is reasonable to expect that external review, quality of care, and ultimately the patient will benefit. Uniformity in forms and documentation standards across various sites may also be of benefit to the education of residents and medical students rotating through community physicians' offices, as well as assist in compliance with. payor's requests.

In a managed care setting, physicians may be reimbursed on a case-by-case basis for performing examinations with elements defined by a government agency such as Medicaid Early Periodic Screening, Diagnosis and Treatment (EPSDT) programs. The required elements of an EPSDT examination include a full history and physical examination, immunizations, screening, and nutritional and developmental counseling. These EPSDT examinations must be done at regular intervals throughout childhood. Ensuring compliance with these and other standards of care can be greatly facilitated by including prompts and reminders on a structured form. Thus, the usefulness of standardized forms may extend outside strict clinical utility into the financial and administrative realms.

Ultimately, the medical record, a document that serves a wide range of essential functions in clinical care and research, should contain the most complete and accurate account of examinations and treatment possible. Our study showed that standardized, age-specific forms are an effective way to improve the completeness of documentation for well-child examinations across practicing providers.

TABLE.

Comparison of Mean Completeness of Documentation Scores Before and After
Introduction of Age-Specific Structured Encounter Forms

Component                Period   Mean  No.  P Value   SD

Overall documentation    Before  .3535  96            .1251
                         After   .7762  96   <.0001   .1532
Growth and development   Before  .1771  96            .1648
                         After   .8156  96   <.0001   .2083
Physical examination     Before  .6543  96            .2095
                         After   .9457  96   <.0001   .1060
Anticipatory guidance    Before  .0780  96            .2569
                         After   .5859  96   <.0001   .4260
Health counseling        Before  .1947  96            .3924
                         After   .7153  96   <.0001   .4216
Nutrition counseling     Before  .4570  96            .4913
                         After   .7639  96   <.0001   .3443
Psychosocial counseling  Before  .0139  96            .1050
                         After   .3741  96   <.0001   .3967
Safety counseling        Before  .3021  96            .4467
                         After   .7339  96   <.0001   .3757

SD = Standard deviation.

Acknowledgments. We thank Frances Glascoe, PhD, for manuscript review; Kelly Montgomery, MPH, for allowing review and incorporation of her Masters Thesis methodology; and Jean Davis, RN, of the JMH Health Plan.

References

(1.) Grant P: Standardized forms in pediatrics: an idea whose time has come. Conlemp Pediatr 1994; 11:1-7

(2.) Duggan AK, Starfield B, De Angelis C: Structured encounter form: the impact on provider performance and recording of welt child care. Pediatrics 1990; 85:104-113

(3.) zenni EA, Robinson TN: Effects of structured encounter forms on pediatric house staff knowledge, parent satisfaction, and quality of care, a randomized, controlled trial. Arch Pediatr Adolesc Med 1996; 150:975-980

(4.) wrenn K, Rodewald L, Lumb E, et al: The use of structured, complaint specific patient encounter forms in the emergency department. Ann Emerg Med 1993; 22:805-812

(5.) Joint commission on Accreditation of Health care Organizations Report.] Qual Improve 1995; 21:87-96

(6.) Norman LA, Hardin PA, Lester E, et al: computer-assisted quality improvement in an ambulatory care setting: a follow-up report. J Qual Improve 1995; 21:116-131

(7.) cowan JA, Heckerling PS, Parker JB: Effect of a fact sheet reminder on performance of the periodic health examination: a randomized control trial. Am J Prev Med 1992; 8:104-109

(8.) Gitterman B, Melinkovich P: The impact of standardized, age-specific, well-child encounter forms on preventive pediatric services (Abstract). Am J Dis Child 1993; 147:474

(9.) Madlon-Kay DJ: Use of a structured encounter form to improve well-child care documentation. Arch Earn Med 1998; 7:480-483

(10.) Guidelines For Health Supervision II. Elk Grove Village, Ill American Academy of Pediatrics, 1988

RELATED ARTICLE: KEY POINTS

* This study focused on the documentation of the components of a well-child examination performed by practicing community physicians.

* The setting is urban community health clinics rather than an academic tertiary care center.

* There was an average overall increase of 42% in completeness of documentation after introduction of the forms.

* Improvements in completeness of documentation were significant for all participants and occurred in each major sub-component of the well-child visit that was assessed.

From the Department of Pediatrics and the Department of Epidemiology and Public Health, University of Miami School of Medicine, Miami, Fla.

Reprint requests to Penny Grant, MD, University of Oklahoma School of Medicine-Tulsa, Department of Pediatrics, 2829 S Sheridan Rd, Tulsa, OK 74129.