Using the electronic medical record to improve asthma severity documentation and treatment among family medicine residents.
OBJECTIVE
Use of electronic medical records (EMRs) is being advocated to improve quality of care. The objectives of this study were (1) to determine the effect of EMR template use on family medicine residents' documentation of the severity classification of asthma and (2) to determine if documentation leads to appropriate treatment.


METHODS
We reviewed the charts of patients with asthma seen by residents in the Center for Family Medicine (CFM) between July 1, 2007, and December 31, 2007. Data gathered from each chart included disease severity classification, medication regimen, and use of the asthma template. In July 2008, efforts at increasing residents' knowledge of asthma severity classification and documentation via EMR were made. A post-intervention chart review was performed on patients with asthma seen by the residents between July 1, 2008, and December 31, 2008.


RESULTS
Documentation of asthma severity increased significantly from 24% in the pre- to 44% in the post-intervention phase. Use of the EMR template significantly increased the rate of inhaled corticosteroid prescriptions, from 36.7% to 71.1%.


CONCLUSIONS
Use of an asthma template within the EMR improves documentation of asthma severity and appropriate treatment.
Davis
Angela M
AM
Spartanburg Family Medicine Residency Program, Spartanburg, SC, USA.
Cannon
Matthew
M
Ables
Adrienne Z
AZ
Bendyk
Heather
H
D000328:Adult; D001249:Asthma / Q000145:classification / Q000188:drug therapy / Q000503:physiopathology*; D004282:Documentation; D005194:Family Practice / Q000193:education*; D005260:Female; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008485:Medical Audit; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012189:Retrospective Studies; D012720:Severity of Illness Index