Standardized Note Templates Improve Electronic Medical Record Documentation of Neurovascular Examinations for Pediatric Supracondylar Humeral Fractures

Abstract

Background: Optimization of the electronic medical record (EMR) is essential to support the clinician and to improve the quality and efficiency of patient care. The present report describes the development and implementation of a standardized template that is embedded in the EMR and is focused on a comprehensive physical examination during the evaluation of pediatric supracondylar humeral fractures. We compared the completeness of physical examinations as well as the timing of detection and documentation of neurovascular injuries before and after implementation of the template. We hypothesized that the use of a template would increase the completeness of examinations and would lead to earlier documentation of neurovascular injuries.

Methods: A multidisciplinary quality-improvement task force was created to address neurovascular documentation practices for patients who underwent operative treatment of supracondylar humeral fractures. Following a series of formative and process evaluations, a standardized EMR template was implemented. Neurovascular examination documentation practices that were in use before (pre-template group, n = 224) and after (template group, n = 300) the implementation of the template were compared. Logistic regression analyses of the 2 groups were used to compare the likelihood of a complete neurovascular examination and the timing of neurovascular injury identification.

Results: There was significant improvement in the documentation of the vascular (odds ratio [OR], 70.7; 95% confidence interval [CI], 39.5 to 126.6; p < 0.0001), motor (OR, 17.6; 95% CI, 9.5 to 32.7; p < 0.0001), and sensory (OR, 23.9; 95% CI, 12.9 to 44.4; p < 0.0001) examinations in the template group. Neurological injuries were more likely to be identified preoperatively in the template group compared with the pre-template group (OR, 6.8; 95% CI, 1.7 to 27.1; p = 0.0067).

Conclusions: The incorporation of a standardized template in the EMR improved the completeness and timing of documentation of neurological injury. Standardized EMR templates developed by a clinically driven multidisciplinary task force have the potential to improve the quality of clinical documentation and to ease communication among providers.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1

Chart detailing patient enrollment. Patients were excluded from the pre-template (top left) and template (top right) groups for the reasons indicated in the boxes to the right of each vertical line. The number of patients included in each group is noted in the 2 boxes at the bottom of the chart.

Fig. 2

Flowchart outlining the iterative methodology used to develop, implement, and refine the standardized note templates. The creation and implementation of the standardized template at our institution was a long and detailed process that took almost 2 years to complete, from 2011 to 2013. This process included standard note development (June 2011 to August 2012), formative evaluation (June 2011 to August 2012), and process evaluation (June 2012 to July 2012). The final step of template implementation at our institution was an ongoing outcomes/improvement process (August 2012 to August 2013), which involved the template group described in the present study.