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Article Title

Participation in Quality Improvement: Provider Perceptions Regarding Documentation Audits

Publication Date

4-30-2015

Keywords

peer documentation audits, perceptions of peer audits

Abstract

Background/Aims: Effective communication within health care depends on accurate documentation of assessments, plans and delivered care. Use of electronic medical records (EMRs) requires relearning and evaluating documentation processes for providers, and problems can arise when consistent use of entry fields is not maintained. At each phase of obstetric care, providers require accurate information. In shared practices, prenatal care consists of multiple office visits with multiple providers, focused on maternal/fetal status, accurate dating, and risk factor identification. Information accuracy is important at all phases, but especially so when laboring women present. In our HMO, all providers receive training on EMR use with further training following technology updates. Nevertheless, considerable variability exists in documentation practices. The EMR’s comprehensive nature leads to different tabs, fields and pages where same information can be entered. Data entered into one tab/field may not automatically populate other fields as the provider expects (e.g. problem identified during visit does not make it to the list of patient problems entered on initial visit). Currently, there is no assessment of provider documentation skills or EMR completeness. This quality improvement project (QIP) aims for better documentation, with a secondary goal of mutual learning through peer auditing.

Methods: Our midwifery group, members of an obstetrical team in Southern California, initialized peer audits for initial prenatal care visits. Provider perceptions of reluctance, time involvement and learning (from the Conscious Competence Learning Model) are currently being evaluated before/after the initial cycle of peer audit process. All eligible midwifery service members are participating. The Fall 2014 QIP has two components: pre/post surveys and two rounds of EMR audits. Surveys will assess perceptions of time required for audits, attitudes about the effectiveness of audits and ideas for improving the audit process. Group meetings after each audit cycle will focus on concepts of shared learning and ideas for improving documentation.

Results: Comparison of audit composite objective ratings will detect changes in overall documentation behaviors. Survey results will determine whether the group’s perceptions change and whether value is seen in ongoing audit cycles.

Discussion: This project will demonstrate whether using audit cycles enhance documentation and shared learning among participating midwives.

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