title: Improved documentation of wound care with a structured encounter form in the pediatric emergency department.
abstract: OBJECTIVE
  Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital.
  
  
  METHODS
  The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care.
  
  
  RESULTS
  Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting.
  
  
  CONCLUSIONS
  In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.
authors: Division of Emergency Medicine, Children's Hospital and Health Center, San Diego, CA 92123-4282, USA. jkanegaye@chsd.org
authors: John T
authors: JT
authors: Kanegaye
authors: Jerry C
authors: JC
authors: Cheng
authors: R Ian
authors: RI
authors: McCaslin
authors: Douglas
authors: D
authors: Trocinski
authors: Patricia D
authors: PD
authors: Silva
mesh_terms: D002140:California; D002648:Child; D004282:Documentation / Q000379:methods / Q000592:standards*; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000592:standards*; D005568:Forms and Records Control / Q000379:methods*; D006776:Hospitals, Pediatric; D006784:Hospitals, Teaching; D006801:Humans; D007396:Internship and Residency; D008501:Medical Records, Problem-Oriented; D008505:Medical Staff, Hospital; D009722:Nurse Practitioners; D010348:Patient Care Team / Q000592:standards; D017064:Process Assessment, Health Care; D011446:Prospective Studies; D017749:Total Quality Management / Q000379:methods*; D014947:Wounds and Injuries / Q000175:diagnosis / Q000628:therapy*