Improved documentation of wound care with a structured encounter form in the pediatric emergency department.
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.
Kanegaye
John T
JT
Division of Emergency Medicine, Children's Hospital and Health Center, San Diego, CA 92123-4282, USA. jkanegaye@chsd.org
Cheng
Jerry C
JC
McCaslin
R Ian
RI
Trocinski
Douglas
D
Silva
Patricia D
PD
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*