Use of a structured encounter form to improve well-child care documentation.
OBJECTIVE
To determine if a structured encounter form for well-child care improves documentation of well-child care.


METHODS
Retrospective medical record review of a before-and-after trial.


METHODS
Family practice residency clinic serving a primarily low-socioeconomic urban population.


METHODS
Children younger than 6 years receiving well-child care visits.


METHODS
Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force.


METHODS
Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form.


RESULTS
A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form.


CONCLUSIONS
The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.
Madlon-Kay
D J
DJ
Department of Family and Community Medicine, St Paul Ramsey Medical Center, MN, USA.
D002648:Child; D002662:Child Health Services / Q000458:organization & administration* / Q000592:standards; D004282:Documentation / Q000592:standards; D005194:Family Practice / Q000193:education / Q000458:organization & administration; D005568:Forms and Records Control; D006801:Humans; D007396:Internship and Residency; D008499:Medical Records / Q000592:standards*; D008910:Minnesota; D010044:Outpatient Clinics, Hospital; D011314:Preventive Health Services / Q000458:organization & administration* / Q000592:standards; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D014505:Urban Population