Improving Documentation of Inpatient Problem List in Electronic Health Record: A Quality Improvement Project

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Abstract

Background

The problem list is critical in electronic documentation. It is a powerful tool for clinical decision-making because it provides a concise view of all patient problems in one place and is also a criterion for the Medicare meaningful use incentive program.

Objective

To measure the rate of utilization of problem list in electronic health records (EHR) in a pediatric hospital medicine unit and implement sequential interventions to increase the rate of use of problem list to more than 80% by the end of 2015, as measured by at least one documented hospital problem at discharge.

Methods

We performed a quality improvement process starting with a series of educational interventions. Gradual electronic changes were also made in our EHR to reach our goal.

Results

The use of the problem list for pediatric hospital medicine rose from 47% to 100% in June 2015 and continues to maintain well above the goal of 80%. The problem list usage throughout the children's hospital also rose to 100% within 9 months of project implementation.

Conclusions

Educational interventions and technology leveraging allowed us to achieve and sustain improvement in appropriate problem list usage.

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