A pilot trial of a computerized renal template note to improve resident knowledge and documentation of kidney disease

Abstract

Background: Kidney disease is under-documented in physician notes. The use of template-guided notes may improve physician recognition of kidney disease early in training.

Objective: The objective of this study was to determine whether a computerized inpatient renal template note with clinical decision support improves resident knowledge and documentation of kidney disease.

Methods: In this prospective study, first year medical residents were encouraged to use the renal template note for documentation over a one-month period. The renal template note included an option for classification of acute kidney injury (AKI) and chronic kidney disease (CKD) categories with a link to standard classifications. Pre- and post-knowledge of AKI and CKD categories was tested with a quiz and surveys of resident experience with the intervention were conducted. Appropriate AKI and/or CKD classification was determined in 100 renal template notes and 112 comparable historical internal medicine resident progress notes from approximately one year prior.

Results: 2,435 inpatient encounters amongst 15 residents who participated were documented using the renal template note. A significantly higher percent of residents correctly staged earlier stage CKD (CKD3) using the renal template note compared to historical notes (9/46 vs. 0/33, p<0.01). Documentation of AKI and more advanced CKD stages (CKD4 and 5) did not improve. Knowledge based on quiz scores increased modestly but was not significant. The renal template note was well received by residents and was perceived as helping improve knowledge and documentation of kidney disease.

Conclusion: The renal template note significantly improved staging of earlier stage CKD (CKD3) with a modest but non-significant improvement in resident knowledge. Given the importance of early recognition and treatment of CKD, future studies should focus on teaching early recognition using template notes with supplemental educational interventions.

Keywords: Clinical decision support systems; electronic medical records; kidney disease; medical education; templates.

Fig 1.

The study note incorporated into the computerized progress note template. Residents were prompted to click on the appropriate classification of their patient’s kidney disease. When the AKI or CKD box was clicked, residents were prompted to sub-classify AKI into risk, injury, failure or loss categories based on the Acute Dialysis Quality Initiative (ADQI) – Risk, Injury, Failure, Loss or End Stage Renal Disease (RIFLE) classification scheme [3] and/or to sub-classify CKD into stages based on the Kidney Disease Improving Global Outcomes (KDIGO) guidelines [4]. Clinical decision support for the template note consisted of a link embedded in the progress note to an intranet webpage where residents could obtain RIFLE classification guidelines, CKD staging guidelines and a simplified 4-variable Modification of Diet in Renal Disease (MDRD) estimated glomerular filtration rate (GFR) calculator.