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      Strategies for improving physician documentation in the emergency department: a systematic review

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          Abstract

          Background

          Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown.

          Methods

          We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation.

          Results

          Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results.

          Conclusions

          Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.

          Electronic supplementary material

          The online version of this article (10.1186/s12873-018-0188-z) contains supplementary material, which is available to authorized users.

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          Most cited references72

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          Definition, structure, content, use and impacts of electronic health records: a review of the research literature.

          This paper reviews the research literature on electronic health record (EHR) systems. The aim is to find out (1) how electronic health records are defined, (2) how the structure of these records is described, (3) in what contexts EHRs are used, (4) who has access to EHRs, (5) which data components of the EHRs are used and studied, (6) what is the purpose of research in this field, (7) what methods of data collection have been used in the studies reviewed and (8) what are the results of these studies. A systematic review was carried out of the research dealing with the content of EHRs. A literature search was conducted on four electronic databases: Pubmed/Medline, Cinalh, Eval and Cochrane. The concept of EHR comprised a wide range of information systems, from files compiled in single departments to longitudinal collections of patient data. Only very few papers offered descriptions of the structure of EHRs or the terminologies used. EHRs were used in primary, secondary and tertiary care. Data were recorded in EHRs by different groups of health care professionals. Secretarial staff also recorded data from dictation or nurses' or physicians' manual notes. Some information was also recorded by patients themselves; this information is validated by physicians. It is important that the needs and requirements of different users are taken into account in the future development of information systems. Several data components were documented in EHRs: daily charting, medication administration, physical assessment, admission nursing note, nursing care plan, referral, present complaint (e.g. symptoms), past medical history, life style, physical examination, diagnoses, tests, procedures, treatment, medication, discharge, history, diaries, problems, findings and immunization. In the future it will be necessary to incorporate different kinds of standardized instruments, electronic interviews and nursing documentation systems in EHR systems. The aspects of information quality most often explored in the studies reviewed were the completeness and accuracy of different data components. It has been shown in several studies that the use of an information system was conducive to more complete and accurate documentation by health care professionals. The quality of information is particularly important in patient care, but EHRs also provide important information for secondary purposes, such as health policy planning. Studies focusing on the content of EHRs are needed, especially studies of nursing documentation or patient self-documentation. One future research area is to compare the documentation of different health care professionals with the core information about EHRs which has been determined in national health projects. The challenge for ongoing national health record projects around the world is to take into account all the different types of EHRs and the needs and requirements of different health care professionals and consumers in the development of EHRs. A further challenge is the use of international terminologies in order to achieve semantic interoperability.
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            Are multifaceted interventions more effective than single-component interventions in changing health-care professionals’ behaviours? An overview of systematic reviews

            Background One of the greatest challenges in healthcare is how to best translate research evidence into clinical practice, which includes how to change health-care professionals’ behaviours. A commonly held view is that multifaceted interventions are more effective than single-component interventions. The purpose of this study was to conduct an overview of systematic reviews to evaluate the effectiveness of multifaceted interventions in comparison to single-component interventions in changing health-care professionals’ behaviour in clinical settings. Methods The Rx for Change database, which consists of quality-appraised systematic reviews of interventions to change health-care professional behaviour, was used to identify systematic reviews for the overview. Dual, independent screening and data extraction was conducted. Included reviews used three different approaches (of varying methodological robustness) to evaluate the effectiveness of multifaceted interventions: (1) effect size/dose-response statistical analyses, (2) direct (non-statistical) comparisons of multifaceted to single interventions and (3) indirect comparisons of multifaceted to single interventions. Results Twenty-five reviews were included in the overview. Three reviews provided effect size/dose-response statistical analyses of the effectiveness of multifaceted interventions; no statistical evidence of a relationship between the number of intervention components and the effect size was found. Eight reviews reported direct (non-statistical) comparisons of multifaceted to single-component interventions; four of these reviews found multifaceted interventions to be generally effective compared to single interventions, while the remaining four reviews found that multifaceted interventions had either mixed effects or were generally ineffective compared to single interventions. Twenty-three reviews indirectly compared the effectiveness of multifaceted to single interventions; nine of which also reported either a statistical (dose-response) analysis (N = 2) or a non-statistical direct comparison (N = 7). The majority (N = 15) of reviews reporting indirect comparisons of multifaceted to single interventions showed similar effectiveness for multifaceted and single interventions when compared to controls. Of the remaining eight reviews, six found single interventions to be generally effective while multifaceted had mixed effectiveness. Conclusion This overview of systematic reviews offers no compelling evidence that multifaceted interventions are more effective than single-component interventions. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0152-6) contains supplementary material, which is available to authorized users.
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              Electronic health records implementation: an evaluation of information system impact and contingency factors.

              This paper provides a review of EHR (electronic health record) implementations around the world and reports on findings including benefits and issues associated with EHR implementation.
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                Author and article information

                Contributors
                dllorenz@ucalgary.ca
                hquan@ucalgary.ca
                klucyk@ucalgary.ca
                ceara.cunningham@albertahealthservices.ca
                deirdre.hennessy@canada.ca
                jason.jiang@albertahealthservices.ca
                cabeck@ucalgary.ca
                Journal
                BMC Emerg Med
                BMC Emerg Med
                BMC Emergency Medicine
                BioMed Central (London )
                1471-227X
                25 October 2018
                25 October 2018
                2018
                : 18
                : 36
                Affiliations
                [1 ]ISNI 0000 0004 1936 7697, GRID grid.22072.35, Department of Community Health Sciences, , Cumming School of Medicine, University of Calgary, ; 3330 Hospital Drive NW, Calgary, AB T2N4N1 Canada
                [2 ]ISNI 0000 0004 1936 7697, GRID grid.22072.35, Department of Psychiatry, , Cumming School of Medicine, University of Calgary, ; 3330 Hospital Drive NW, Calgary, AB T2N4N1 Canada
                Author information
                http://orcid.org/0000-0001-8423-3458
                Article
                188
                10.1186/s12873-018-0188-z
                6297955
                30558573
                4299ca68-0e7b-4a86-a83f-7b55d44ff013
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 2 May 2018
                : 12 October 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;
                Award ID: 111753
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Emergency medicine & Trauma
                documentation,emergency departments,medical records,physicians,systematic reviews

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