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The primary purpose of medical records is to support patient care. It is a means of communication and secondarily, it is an important medicolegal document. Current standards of clinical records are variable. The aim of this study was to assess the adequacy of case notes in a tertiary care hospital and compare it with that of world standards. 231 case records of inpatients in the general surgery department who were discharged were audited retrospectively. Out of 53 standards analyzed, 7 had 100% compliance. More than 75% of compliance was achieved in 30/53 standards. A significant lapse in record keeping was found in daily entries by doctors, the timing of entries, details of initial assessment, and daily progress notes. Maintaining high-quality clinical record is an important part of our responsibility. Deficiencies show up in formal audits of case records. Regular orientation programs to improve the quality of clinical records and regular auditing of case notes are required to ensure adequacy. [ABSTRACT FROM AUTHOR]

Introduction Physicians enter residency with varied knowledge regarding the purpose of progress notes and proficiency writing them. The objective of this study was to test whether resident knowledge, beliefs, and confidence writing inpatient progress notes improved after a 2.5-hour workshop intervention. Methods An educational workshop and note assessment tool was constructed by resident and faculty stakeholders based on a review of literature and institutional best practices. The Progress Note Assessment and Plan Evaluation (PNAPE) tool was designed to assess adherence to best practices in the assessment and plan section of progress notes. Thirty-four residents from a midsized pediatric residency program attended the workshop, which consisted of didactics and small-group work evaluating sample notes using the PNAPE tool. Participants completed a four-question online pre- and postworkshop survey to evaluate their knowledge of progress note components and attitudes regarding note importance. Pre-post analysis was performed with Chi-square testing for true/false questions, and Mann-Whitney testing for Likert scale questions and summative scores. Results A majority of pediatric residents completed the preintervention (n = 26, 76% response rate) and postintervention (n = 23, 68% response rate) surveys. Accurate response rate improved in 15 of 20 of the true/false items, with a statistically significant improvement in five items. Resident perceptions of note importance and confidence in note writing also increased. Discussion A workshop intervention may effectively educate pediatric residents about progress note best practices. Further studies should assess the impact of the intervention on sustained knowledge and beliefs about progress notes and subsequent note quality.

Introduction: The minimum data set is a standard method for collecting key data elements, which will finally improve healthcare and quality of treatment services. Electronic documentation in the intensive care unit (ICU) has a significant effect on the quality of data. In addition, using structured data and standard formats can facilitate documentation of progress note data. Therefore, the aim of this study was to create a minimum data set for an effective design and implementation of electronic documentation of progress note in the ICU. Material and Methods: This is an applied qualitative study conducted in the general intensive care unit of Namazi hospital in Shiraz, which is the largest education and treatment center in Shiraz and the only referral hospital in Southern Iran. In this study, four stages were used for designing the minimum data sets of electronic progress note: 1. Using English literature, 2. Local expert review, 3. Designing prototypes, and 4. Conducting group sessions. Finally, data were analyzed using descriptive statistics through SPSS 21 software. Results: The minimum data set for electronic documentation of progress note in the ICU included the two demographic and clinical sections. In addition, the clinical data were classified into 11 major groups, each consisting of other items. Meanwhile, 46.8% (66 out of 141) of information items were obtained from reviewing the literature and 53.2% (76 out of 141) from interviews. In group sessions, 99.29% of information items were finalized by experts. Conclusion: It is essential to create a standard and structured minimum data set for the electronic design and implementation of progress note data. In such a case, accurate, thorough and timely electronic documentation in presenting instantaneous reports on the status of patients is effective in management and clinical decision-makings. [ABSTRACT FROM AUTHOR]

The paper presents a novel solution to the 2022 National NLP Clinical Challenges (n2c2) Track 3, which aims to predict the relations between assessment and plan subsections in progress notes. Our approach goes beyond standard transformer models and incorporates external information such as medical ontology and order information to comprehend the semantics of progress notes. We fine-tuned transformers to understand the textual data and incorporated medical ontology concepts and their relationships to enhance the model's accuracy. We also captured order information that regular transformers cannot by taking into account the position of the assessment and plan subsections in progress notes. Our submission earned third place in the challenge phase with a macro-F1 score of 0.811. After refining our pipeline further, we achieved a macro-F1 of 0.826, outperforming the top-performing system during the challenge phase. Our approach, which combines fine-tuned transformers, medical ontology, and order information, outperformed other systems in predicting the relationships between assessment and plan subsections in progress notes. This highlights the importance of incorporating external information beyond textual data in natural language processing (NLP) tasks related to medical documentation. Our work could potentially improve the efficiency and accuracy of progress note analysis. [Display omitted] • An NLP pipeline that achieved a top-3 performance in 2022 n2c2 Track 3. • Fine-tuned transformer-based models to understand the semantics of progress notes. • Integrated medical ontology and order information to imporve the transformer models. • Designed an ensemble strategy to further boost our system performance. [ABSTRACT FROM AUTHOR]

Abstract Introduction This resource is a series of workshops designed to assist internal medicine residents in developing chart documentation skills. In a series of hour-long workshops, notes written by house staff in both the inpatient and outpatient settings are used as a springboard for discussion. Together with faculty, house staff critique the notes and score them using instruments developed for this purpose. Methods This resource was designed specifically for use with international medical graduates, who often face communication barriers with patients, staff, and faculty due to differences in language and culture, but can be used with any group of internal medicine trainees. Program materials can be modified to suit the needs of educators in other fields of medicine. This resource addresses the Accreditation Council for Graduate Medical Education requirement that internal medicine residency programs review “clinical documentation for format, quality of data entry, accuracy of the assessment, and appropriateness of the plan.” Results In a preimplementation needs assessment, house staff revealed that they value feedback related to chart documentation and would like more formal education in this area. Faculty members also placed value on the teaching of note-writing skills, and were particularly interested in improving the quality of hospital discharge summaries. In extemporaneous commentary, house staff have stated that they consider points learned from this resource on a regular basis during their daily work. House staff have also reported that they have a better understanding of the expected format and content of various notes. A formal postimplementation program evaluation is in progress and will include analysis of house staff self-reported confidence and satisfaction as well as a chart review to measure actual change in quality of notes. Discussion Internal medicine training programs may improve the quality of house staff chart documentation by implementation of this structured series of interactive workshops. House staff value feedback related to their own chart documentation skills, but may be hesitant to publicly provide this feedback to their peers.

Medical students have routinely documented patient encounters in both inpatient and outpatient care venues. This hands-on experience has provided a way for students to reflect on patient encounters, learn proper documentation skills, and attain a sense of being actively involved in and responsible for the care of patients. Over the last several years, the practice of student note writing has come into question. Institutional disincentives to student documentation include insurance regulations that restrict student documentation from substantiating billing claims, concerns about the legal status of student notes, and implementation of electronic medical records that do not allow or restrict student access. The increased scrutiny of the medical record from pay-for-performance programs and other quality measures will likely add to the pressure to exclude students from writing notes. This trend in limiting medical student documentation may have wide-ranging consequences for student education, from delaying the learning of proper documentation skills to limiting training opportunities. This article reviews the educational value of student note writing, the factors that have made student documentation problematic, and the potential educational impact of limiting student documentation. In addition, it offers some suggestions for future research to guide policy in this area. [ABSTRACT FROM AUTHOR]

Background The University of Minnesota Medical Center (UMMC) is a tertiary care facility, which has had a comprehensive antimicrobial stewardship program (ASP) for 12 years. Methods The antimicrobial stewardship team is comprised of a full-time PharmD and ID staff physicians. Recommendations are placed in the electronic medical record as a progress note. Verbal recommendations may also be made. Results There was a downward trend in Hospital-acquired (HA) C. difficile diarrhea from 2007 to 2014 from 1.2 to 0.5/1000 patient-days (pt day). Rates appear stable from 2014 to 2019 with adjustment for change to NHSN lab-based CDI surveillance (Figure 1). From 2009 to 2019 a decrease was seen in VRE hospital-acquired infections (HAI) from 0.53 to 0.21/1,000 patient-days and in MRSA HAIs from 0.2 to 0.14/1,000 patient-days. Newly acquired ESBL HAIs have remained relatively stable from 2009 to 2019 at 0.09 to 0.05/1,000 patient-days. CRE HAIs are low but stable rates at 0.02/1,000 patient-days (Figure 2). We track antimicrobial utilization for internal and national reporting (starting in July 2017). A SAAR for all Antibacterial agents (ICUs, wards, and oncology units) of 1.33 in 2018. Our top four agents average DOT; piperacillin/tazobactam (66.81), cefepime (34.40), oral levofloxacin (23.56) and intravenous meropenem (21.49). We demonstrate lower average DOT for our restricted antimicrobials (206.21) as compared with our nonrestricted antimicrobials (236.74) (Figure 3). Cost savings continued from year to year. After adjusting for inflation annually, our expected costs ($84.08) compared with actual costs ($40.12 ytd 2019), demonstrates effective cost management of antimicrobial agents. (Figure 4) Conclusion We observed a decrease in HAIs VRE and C. difficile infections after 3 years of operation, and MRSA after 5 years. This downward trend has continued. ESBL HAIs remain relatively stable and CRE are stable at low rates but remain emerging HAIs of concern. We are now focusing efforts on limiting unneeded fluoroquinolone and carbapenem use. We continue to analyze our SAAR data and internal DOT data to identify areas of opportunity to improve antimicrobial use. The ASP outcomes have continued to cost justify ongoing efforts. The effects of the program and the Infection Prevention Department appear to be synergistic. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Patients discharged on intravenous antibiotics require regular monitoring by an infectious disease (ID) specialist or other provider familiar with outpatient parenteral antibiotic therapy (OPAT). However, the lab monitoring and outpatient follow-up plan outlined prior to discharge is not always realized. We are working to understand what steps the discharging hospital can take to improve the outpatient monitoring and follow-up for patients on OPAT, who are discharged to a wide variety of institutions. We studied whether documenting the OPAT plan in a standardized note led to increased inclusion of that plan in the discharge documentation and thus to improved lab monitoring and outpatient follow-up for our patients. Methods We compared the pre- and post-intervention frequency of seven key OPAT elements (antibiotic, duration, end date, indication, follow-up appointment, recommend labs, fax number for labs) in the discharge documentation. Pre-intervention, this information was documented by the inpatient ID service in the Problem List (overview) section of the electronic health record. Post-intervention, OPAT plans were documented within standardized OPAT Progress Notes. Efficiency and clinical outcomes were: proportion of OPAT treatment weeks with laboratory monitoring; number of weeks the outpatient ID team had to track down missing laboratory results; number of "No Show" ID clinic visits; number of OPAT-related telephone encounters. Results There were 73 patients in the pre- and 68 in the post-intervention cohort. Having a formal OPAT Progress Note was associated with a significant increase in the number of OPAT elements included in the discharge documentation (7 vs. 5, P = 0.002). In addition, the entire OPAT note was included in the discharge documentation more frequently in the post-intervention cohort (3/73 vs.. 14/68, P = 0.007). However, except for reduced telephone encounters related to OPAT (2 vs. 1 per patient, P = 0.0001), there were no significant improvements in post-discharge clinical or efficiency outcomes. Conclusion Creating an OPAT Progress Note improves the capture of OPAT elements into discharge documentation. Except for reducing telephone encounters, no other benefits occurred. Future interventions will focus on improving the other measured outcomes. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]