The Empty SmartLink Solution: A Quality Improvement Initiative to Improve History and Physical Notes Documentation Using Clinical Decision Support.

Introduction: The use of structured documentation via auto-populated discrete fields is important to facilitate medical decision-making, research, and quality improvement. If these fields are not filed properly, they will appear "empty," leaving behind incomplete documentation. Examples include past medical history (PMH), past surgical history (PSH), family history (FH), and active hospital problems (AHP).

Objectives: Our SMART aim was to decrease the incidence of "no PMH/PSH/FH/AHP on file" in history and physical notes (H&Ps) at our single children's hospital from 7.9%, 18.7%, 8.3%, and 17.0%, respectively, to less than 5% over 4 months.

Methods: A multidisciplinary team utilized quality improvement methodology. The population included all encounters admitted to pediatric hospital medicine. The outcome measure was percentage of H&Ps with "no PMH/PSH/FH/AHP on file." The process measure was percentage of H&Ps using the proper template. Interventions included a clinical decision support tool in H&P templates to display a hard stop if "no PMH/SH/FH/AHP on file" appears and documentation education. Statistical process control charts were used to analyze measures.

Results: "No PMH/PSH/FH/AHP on file" decreased from baseline to 1.2%, 2.2%, 2.9%, and 4.2%, respectively, showing special cause variation. H&P template use remained high at 87.2%.

Conclusions: The creation of a simple clinical decision support tool was associated with a decreased incidence of "no PMH/PSH/FH/AHP on file," achieving our goal. Utilizing automatic clinical decision support reduced the need to rely on education to cause a change, an important element of our tool. Future steps include implementation of a hard stop in other required areas of discrete documentation and ongoing evaluation of sustained change.