Deficiency workflow: Utilizing electronic medical records to improve compliance with point-of-care ultrasound documentation

Abstract

Background

Point-of-care ultrasound (POCUS) is a common modality utilized in emergency departments (EDs). Image acquisition and storage workflows have significantly improved. Saving POCUS images is considered standard of care. However, documentation compliance is a struggle for clinicians in the chaotic ED environment. We sought to implement a simple electronic medical record (EMR) deficiency workflow to improve capture of POCUS documentation and billing in a large healthcare setting.

Methods

A retrospective review of all POCUS studies across 12 EDs was performed from January 1 to December 31, 2023. All EDs utilized the same EMR with standardized workflow. Clinicians were recommended to complete charting within 48 h of patient disposition. A POCUS deficiency workflow was implemented on June 1, 2023 to improve compliance. Deficiency workflow was defined as automated in-basket messaging that appeared after POCUS order entry. Deficiency remained in the clinicians in-basket until procedure note was completed. We compared POCUS chart deficiencies for lack of procedural documentation. Descriptive statistics were performed.

Results

5013 POCUS were reviewed during the study period, 42 % before and 58 % after implementation. There was a 3.0 % absolute reduction (CI 2.01 %, 3.97 %) in procedure note deficiency from the pre-intervention to post-intervention period, 4.44 %. to 1.45 %.

Conclusion

A POCUS deficiency workflow improved documentation across our healthcare system. This directly improved billing of POCUS studies and decreased late chart notifications. This workflow can be implemented in any medical specialty that utilizes POCUS. We recommend large healthcare systems investigate similar workflows to improve documentation and billing of POCUS exams.