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Improved Documentation of Wound Care With a Structured Encounter Form in the Pediatric Emergency Department

  • John T. Kanegaye
    Correspondence
    Address correspondence to John T. Kanegaye, MD, Division of Emergency Medicine, Children's Hospital and Health Center, 3020 Children's Way, MC 5075, San Diego, CA 92123-4282
    Affiliations
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  • Jerry C. Cheng
    Affiliations
    From the Division of Emergency Medicine (Drs Kanegaye, McCaslin, and Trocinski) and Research Center (Ms Silva), Children's Hospital and Health Center, San Diego, Calif; and the Department of Pediatrics (Drs Kanegaye and McCaslin) and School of Medicine (Dr Cheng), University of California, San Diego, Calif
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  • R. Ian McCaslin
    Affiliations
    From the Division of Emergency Medicine (Drs Kanegaye, McCaslin, and Trocinski) and Research Center (Ms Silva), Children's Hospital and Health Center, San Diego, Calif; and the Department of Pediatrics (Drs Kanegaye and McCaslin) and School of Medicine (Dr Cheng), University of California, San Diego, Calif
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  • Douglas Trocinski
    Affiliations
    From the Division of Emergency Medicine (Drs Kanegaye, McCaslin, and Trocinski) and Research Center (Ms Silva), Children's Hospital and Health Center, San Diego, Calif; and the Department of Pediatrics (Drs Kanegaye and McCaslin) and School of Medicine (Dr Cheng), University of California, San Diego, Calif
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  • Patricia D. Silva
    Affiliations
    From the Division of Emergency Medicine (Drs Kanegaye, McCaslin, and Trocinski) and Research Center (Ms Silva), Children's Hospital and Health Center, San Diego, Calif; and the Department of Pediatrics (Drs Kanegaye and McCaslin) and School of Medicine (Dr Cheng), University of California, San Diego, Calif
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      Objective.—Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital.
      Methods.—The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care.
      Results.—Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting.
      Discussion.—In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.

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