Transition to a computer-based record using scannable, structured encounter forms
R. N. Shiffman, C. A. Brandt and B. G. Freeman
Department of Pediatrics, Yale University School of Medicine, New Haven, Conn., USA. richard.shiffman@yale.edu
OBJECTIVE: To evaluate the quality of documentation and user satisfaction
with a structured documentation system for pediatric health maintenance
encounters, using scanned paper-based forms to generate an electronic
medical record. DESIGN: (1) A retrospective medical record review comparing
16 structured (ST) records with 16 contemporaneously created unstructured
records, (2) a questionnaire evaluation of user satisfaction, and (3) an
electronic records review of patients seen 1 year following the full
implementation of the system to evaluate persistence of the effect.
SETTING: The Yale-New Haven Hospital Pediatric Primary Care Center, New
Haven, Conn, an inner-city clinic in an academic center. PARTICIPANTS: (1)
A random sample of 16 health maintenance records completed by first- and
second-year residents in February 1996 matched for patient's age and
provider training level with 16 contemporaneously documented visits, (2) 16
of 18 pediatric level 1 residents and 14 of 16 pediatric level 2 residents
who completed questionnaires, and (3) all electronic records of health
maintenance visits during February 1997. MAIN OUTCOME MEASURES: The number
of data elements documented and the percentage of records that record
specific components of the health maintenance encounter. User satisfaction
was specified on a Likert scale. RESULTS: Overall, residents in the ST
records group documented more data elements per visit than did those in the
unstructured records group. The number of developmental items documented
was 11.5 per visit in the ST records group and 4.8 per visit in the
unstructured records group (P = .004). Likewise, anticipatory guidance was
more thoroughly documented in the ST records group--8.3 items per visit vs
2.5 items per visit (P < .001). Ninety percent of the users preferred
the ST records. One year after the adoption of the ST recording system,
high levels of thoroughness persisted. CONCLUSIONS: Structured, scannable
encounter forms can facilitate documentation of patient care and are well
accepted by users. They can provide an effective mechanism to ease the
transition to a computer-based patient record.
