Ambulatory Pediatrics
Volume 5, Issue 4 , Pages 253-257, July 2005

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

  • John T. Kanegaye, MD

      Affiliations

    • Corresponding Author InformationAddress 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
    • ,
  • Jerry C. Cheng, MD

      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
    • ,
  • R. Ian McCaslin, MD

      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
    • ,
  • Douglas Trocinski, MD

      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
    • ,
  • Patricia D. Silva, MS

      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

Received 9 November 2004; accepted 27 February 2005.

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.

KEY WORDS:  documentation , education graduate , lacerations , medical graduate , medical records

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 This work was presented orally at the Ambulatory Pediatric Association (Region IX, X) Meeting, Carmel, Calif, February 11, 2001, and in poster format before the Ambulatory Pediatric Association Emergency Medicine Special Interest Group, Pediatric Academic Societies Annual Meeting, Baltimore, Md, April 29, 2001.Reprints not available from the authors.

PII: S1530-1567(05)60212-2

doi:10.1367/A04-196R.1

Ambulatory Pediatrics
Volume 5, Issue 4 , Pages 253-257, July 2005

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