Xin Piao, Brian H Imdieke, Samantha A Sommerness, Deepti Pandita
{"title":"An Evidence-based Preoperative Evaluation Documentation Template Improves Perioperative Communication.","authors":"Xin Piao, Brian H Imdieke, Samantha A Sommerness, Deepti Pandita","doi":"10.1055/s-0044-1779021","DOIUrl":null,"url":null,"abstract":"<p><strong>Objectives: </strong>The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.</p><p><strong>Methods: </strong>We implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.</p><p><strong>Results: </strong>The preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template \"went live\" (<i>p</i> < 0.001). Clinician satisfaction with the preoperative documentation template also significantly increased (30.6 vs. 80.0%, <i>p</i> < 0.001).</p><p><strong>Conclusion: </strong>Adopting a user-friendly, evidence-based documentation template can enhance the standardization of preoperative evaluation documentation and reduce the documentation burden.</p>","PeriodicalId":48956,"journal":{"name":"Applied Clinical Informatics","volume":null,"pages":null},"PeriodicalIF":2.1000,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10866639/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Applied Clinical Informatics","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1055/s-0044-1779021","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/2/14 0:00:00","PubModel":"Epub","JCR":"Q4","JCRName":"MEDICAL INFORMATICS","Score":null,"Total":0}
引用次数: 0
Abstract
Objectives: The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative pathway but also enhanced the overall user experience.
Methods: We implemented a revamped evidence-based documentation template in the electronic medical records of a health care organization across three internal medicine clinics on the downtown campus and seven satellite family medicine clinics. A pre- and postintervention design was used to assess the template utilization rate and clinician satisfaction.
Results: The preoperative template utilization rate increased from 51.2% at baseline to 66.5% after the revamped template "went live" (p < 0.001). Clinician satisfaction with the preoperative documentation template also significantly increased (30.6 vs. 80.0%, p < 0.001).
Conclusion: Adopting a user-friendly, evidence-based documentation template can enhance the standardization of preoperative evaluation documentation and reduce the documentation burden.
期刊介绍:
ACI is the third Schattauer journal dealing with biomedical and health informatics. It perfectly complements our other journals Öffnet internen Link im aktuellen FensterMethods of Information in Medicine and the Öffnet internen Link im aktuellen FensterYearbook of Medical Informatics. The Yearbook of Medical Informatics being the “Milestone” or state-of-the-art journal and Methods of Information in Medicine being the “Science and Research” journal of IMIA, ACI intends to be the “Practical” journal of IMIA.