LAUSR

BACKGROUND Clinical documentation is a key component of practice. Trainees rarely receive formal training in documentation or assessment of their documentation. Effective methods of improving documentation remain unknown. OBJECTIVE The objective of this study was to determine if the implementation of a documentation curriculum led to improvement in admission note quality. DESIGNS Admission notes written prior to implementation of the curriculum and after the curriculum intervention were assessed. Notes were assessed from two-time frames for both years to account for improvement with time not associated with the intervention. SETTINGS AND PARTICIPANTS Admission notes written by University of Cincinnati interns were assessed. INTERVENTIONS The documentation curriculum consisted of educational sessions and routine admission note assessments with feedback. MAIN OUTCOMES AND MEASURES Admission notes were assessed via the 16 checklist items and two global assessment items of the Admission Note Assessment Tool (ANAT). RESULTS Six ANAT items showed statistically significant differences. The review of systems item improved with the intervention only (odds ratio: 3.61, p < .001) while the assessment and plan item 1 and global assessment item 2 improved with time only (β = .08, p = .03 and β = .25, p = .02, respectively) in univariate models. In univariate models the physical exam item, diagnostic data item 2, and global assessment item 1 showed improvement with both intervention and time, respectively, with additive effects seen in models with both intervention and time. CONCLUSION Several aspects of documentation can improve with a formal documentation curriculum which includes a routine assessment with feedback, and some aspects of documentation improve with time.