title: Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record.
abstract: Communication errors are identified as a root cause contributing to a majority of sentinel events. The clinical note is a cornerstone of physician communication, yet there are few published interventions on teaching note writing in the electronic health record (EHR). This is a prospective, two-site, quality improvement project to assess and improve the quality of clinical documentation in the EHR using a validated assessment tool.
  
  
  
  Internal Medicine (IM) residents at the University of Kentucky College of Medicine (UK) and Montefiore Medical Center/Albert Einstein College of Medicine (MMC) received one of two interventions during an inpatient ward month: either a lecture, or a lecture and individual feedback on progress notes. A third group of residents in each program served as control. Notes were evaluated with the Physician Documentation Quality Instrument 9 (PDQI-9).
  
  
  
  Due to a significant difference in baseline PDQI-9 scores at MMC, the sites were not combined. Of 75 residents at the UK site, 22 were eligible, 20 (91%) enrolled, 76 notes in total were scored. Of 156 residents at MMC, 22 were eligible, 18 (82%) enrolled, 40 notes in total were scored. Note quality did not improve as measured by the PDQI-9.
  
  
  
  This educational quality improvement project did not improve the quality of clinical documentation as measured by the PDQI-9. This project underscores the difficulty in improving note quality. Further efforts should explore more effective educational tools to improve the quality of clinical documentation in the EHR.
authors.affiliation: Laura Fanucchi, MD, MPH, Center for Health Services Research, Assistant Professor of Medicine, University of Kentucky College of Medicine, 900 South Limestone, 306B Charles T. Wethington Bldg, Lexington, KY 40536, Ph: 859-323-1982, Fax: 859-257-2605, Email: laura.fanucchi@uky.edu.
authors.forename: Laura
authors.initials: L
authors.lastname: Fanucchi
authors.forename: Donglin
authors.initials: D
authors.lastname: Yan
authors.forename: Rosemarie L
authors.initials: RL
authors.lastname: Conigliaro
mesh_terms: D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records; D006801:Humans; D058996:Quality Improvement
keywords: Electronic health record; clinical documentation; medical education