Once implemented, the accolades and success stories for the template progress notes began flowing. Other non-hospitalist physicians at the hospital liked the idea so much that they created their own. A local pulmonologist said, “The progress note template is a great idea. It cuts out the time you waste documenting routine items and gives you more time and highlights the thoughts that you document in the discussion section.” His group later created and implemented their own template progress note specifically for ICU patients, based upon our template.
The progress note decreased the time to document each patient by approximately 42 seconds. This may not seem substantial, but multiplied by 18 patients per day (our average), this equated to over 12 minutes each day, over an hour each week, and over 60 hours a year per hospitalist.
After about 6 months of experience and success with the progress note templates, the hospital approached us to make a standardized progress note that could be used by the entire staff (Figure 1). They also wanted to incorporate Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality indicators such as smoking cessation documentation and vaccination status. We submitted our form with some modifications, and the hospital approved and published it as an official progress note template. When the hospital was inspected by JCAHO in March of 2005, it received accolades for this quality improvement tool.
This template was created with the input of our group as an initiative to have a system-wide progress note for Internal Medicine based on the success our hospitalist group had with the template progress note. (Reproduced with permission from LMHS.)
Implementing documentation of DVT prophylaxis (if applicable) was one of our original motivations for the progress note. With a check box at the top of the template note, hospitalists were faced with this documentation on every patient. We also reinforced the DVT prophylaxis with quarterly educational sessions. A DVT prophylaxis order set (Figure 2) with DVT prophylaxis indications and recommendations was also encouraged and utilized during this period of time. DVT prophylaxis compliance in our group went from less than 50% to nearly 100% during the first year of implementing the hospital progress note.
Another potential benefit may be coding compliance. Prior to implementation, we had a substantial failure rate on Medicare audits. We suspect that this number will be substantially reduced with detailed physical examination documentation built into the template, although corroborating data are not available.
Based upon our experience, a hospitalist progress note template is a promising tool with regard to time efficiency, coding compliance, and quality improvement. The electronic medical record will likely soon become the standard of inpatient documentation. The template progress note may serve as an efficient tool in the meantime and may even serve as a basis for the hospitalist electronic templates, as electronic medical records are often template based.
References
- McDonald CJ. Protocol-based reminders, the quality of care, and the non-perfectibility of man. N Engl J Med. 1976;295: 1351-5.
- Overhage JM, Tierney WM, Zhou X, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission. J Am Med Inform Assoc. 1997;4: 364-71.
- Nilasena DS, Lincoln MJ. A computer-based reminder system improved physician compliance with diabetes preventive care guidelines. Proc 19th Annu Symp Comput Appl Med Care. 1995:640-5.
- Lobach DF, Hammond WE. Development and evaluation of a computer-assisted management protocol (CAMP): improved compliance with care guidelines for diabetes mellitus. Proc 18th Annu Symp Comput Appl Med Care. 1994:787-91.
- Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med Care. 1986;24:659-66.