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Academic Psychiatry, VOL. 28, No. 2
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Brief Report   |   June 01, 2004 
An Educational Intervention to Improve Residents’ Inpatient Charting
Joyce A. Tinsley, M.D.
Academic Psychiatry 2004;28:136-139. 10.1176/appi.ap.28.2.136
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Dr. Tinsley is Director of Psychiatric Residency Training and Associate Professor of Psychiatry at the University of Connecticut Health Center, Farmington, Connecticut. Address correspondence to Dr. Tinsley, Director of Psychiatric Residency Training, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030-1935; tinsley@psychiatry.uchc.edu (E-mail).
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Abstract
Objective: This report describes an educational intervention designed to improve psychiatry residents’ inpatient charting skills. Methods: The residency training committee formed a multidisciplinary team to study the problem by using quality improvement principles. The team hypothesized that residents’ charting would improve with education about the purpose of the medical record and instruction on the specific components to document. The team designed an educational intervention to train residents to record five items in the chart of every inpatient: an admission note, an off-service note, descriptions of medication changes, daily progress notes, and the name and discipline of the individual recording these items. Prior to the educational intervention, a chart abstractor determined the frequency, with which residents charted the five items. Additional chart audits were conducted 1 month and 6 months following education. Results: Compliance in charting four of the five items improved significantly 1 month after education, and the improvement was maintained after 6 months. Conclusion: An educational intervention that is planned and implemented by a multidisciplinary team can enhance an area of resident performance that affects patient care.Abstract Teaser
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    This report describes an educational intervention that was used to clarify the resident’s responsibility for charting on the inpatient psychiatric unit. The expected frequency as well as the content of the residents’ notes had become ill-defined. This had occurred largely because of stricter rules that required attending physicians to provide daily documentation for billing purposes. To some residents and faculty, the residents’ progress notes seemed superfluous because the attending physician also wrote a note. Faculty expressed dissatisfaction with the variability in resident charting and debated the responsibility of teaching this skill.
    The need to standardize resident charting practices on the psychiatric inpatient units became clear when a residency review committee (RRC) citation commented on the lack of evidence that residents had sufficient opportunities to develop clinical skills and professional judgment about inpatient services. Although this citation was debated by both residents and faculty, it was true that evidence for the prominent role of residents in caring for their assigned patients was not apparent from review of the medical record.
    A quality improvement model provided the framework for making the needed changes. Although quality improvement principles are commonly used in medical settings, there are very few reports of quality improvement projects that are applied to an aspect of medical training (+1, +2). The residency training committee decided to use principles common to quality improvement models to address the inpatient charting issue for several reasons: A quality improvement strategy typically involves multiple disciplines, assumes that problems and solutions are discussed from a variety of perspectives, and uses outcome measures to assess interventions. Additionally, the involvement of personnel from several disciplines increased the likelihood that the residency education committee- and hospital-based personnel would share the responsibility for educating residents about charting practices.
    Three of the most important quality improvement principles for this project were the use of a multidisciplinary team of invested members, implementation of a new procedure (the educational intervention in this situation), and measurement of the improved process (+3).
    The hospital’s continuous quality improvement committee provided resources for the project because its aim was relevant to patient care. The planning time for the project described here spanned 3 weeks, and the project took nearly 1 year to complete.
    A multidisciplinary team of eight members was formed. The residency director served as team leader, and the institutional Continuous Quality Improvement (CQI) office assigned a trained nurse facilitator to lend guidance in team meetings. An inpatient nurse manager, a resident, a hospital-based attending physician, and a physician member from the residency education committee represented their constituencies. In addition, there was a record/timekeeper, and the department’s CQI committee assigned a chart auditor to the project.
    The team met three times in weekly 2 to 3 hour blocks. The aims were to clarify residents’ responsibilities for charting, to make the inpatient record a better communication tool for the multiple professionals involved, and to show the residents’ primary role in providing patient care. The team titled the project, "My Patient, My Note," to emphasize the resident physician’s unique responsibility in the care of the patient and the importance of communicating that responsibility in the medical record.
    Team members considered various causes of the charting problems such as inconsistent faculty expectations, treatment team process, the layout of the chart, and resident time management. However, they concluded that lack of resident education and misinformation about charting were causes of the problem that could be remedied. An educational intervention also seemed to have a reasonable likelihood of changing behavior. The team selected five items to train residents to record: 1) admission notes, 2) off-service summaries, 3) daily progress notes, 4) medication changes, and 5) the identity and discipline of the writer.
    Residents were instructed to write the admission or on-service note on the day the resident assumed care of the patient. It should have documented pertinent information for each component of a standard history and examination. Daily notes were to be written, including any medication changes or side effects, and there should have been a note written on the day of discharge or transfer off the unit.
    A baseline audit confirmed charting deficiencies for all selected items, except for the presence of admission notes. Following baseline data collection, residents were taught what needed to be charted and the clinical importance of doing so. The educational effort began with a mandatory lecture for hospital-based residents. The program director, a hospital-based attending physician, and a resident presented the session. Educational posters were placed on the patient care units. Handouts and laminated pocket cards listing the items to chart were distributed to the junior residents to be used as prompts. The chief resident held a follow-up session to reinforce important points and to provide information to those unable to attend the initial lecture; she presented another session midway into the project. Overall implementation of the project was easy; however, the chart abstractions were time-consuming.
    The abstractor collected baseline data from a total of 30 consecutive inpatient charts by recording whether or not each item was documented. The same process was conducted 1 month after the educational session to determine if the frequency of documenting each item had improved and again 6 months later to determine if gains had been maintained.
    Admission notes were almost always written. However, significant improvements in charting the other four items were found 1 month after the educational intervention. Additional gains were seen at the time of the 6-month audit for three of the five items: off-service notes, daily progress notes, and identification of the writer.
    +Figure 1 illustrates the information gathered from the 30 charts that were audited at baseline, 1 month following education, and then 6 months later. An off-service note was found in only 3% of charts prior to the educational intervention. However, an off-service note was found in 60% of charts 1 month posteducation (p<0.001). Improvement was not only maintained 6 months later, but it reached 93% at the final audit (p=0.002). Medication changes were documented in 40% of charts initially and 89% following education (p<0.001); improvement was maintained 6 months later. Compliance with writing a note everyday rose from 3% initially to 60% following education (p<0.001) and continued to improve from 60% to 83% (p=0.008) 6 months later. Residents did not identify themselves by discipline prior to education. Once trained to do so, 63% of charts showed compliance with recording this new item, and 6 months later compliance rose to 90% for this item (p=0.005).
    The initial chart audit revealed an expectedly low percentage of daily notes and properly labeled notes, most likely because clear direction to do this was new. The absence of off-service notes at baseline probably occurred because residents were required to complete a discharge summary; however, they had not been explicitly instructed to make a note in the chart about the circumstances surrounding discharge.
    The team members expected charting behavior to improve immediately after education, and they hoped these gains would be sustained 6 months later. However, they had not expected that even greater gains would be evident at the final audit for documentation of daily notes, proper identification of notes, and off-service notes.
    The educational intervention occurred at the beginning of an academic year. The residents matured as the year progressed, and their documentation may have continued to improve on the basis of their growing experience. However, stage of training is unlikely to fully explain the findings because the baseline audit was conducted during the same time of year as the final audit, meaning that both groups of residents were at the same level of training. It is unlikely that the group audited at baseline was substantially inferior to those audited the following year.
    This project was not undertaken as a research study. Nonetheless, some limitations should be considered when interpreting the results. The chart auditor, residents, and faculty were not blind to the aims of the project. A second limitation may be that each audit was taken from the group of eight junior residents who were assigned to the inpatient service just prior to the audit. The groups were not necessarily made up of the same individuals; rather, they were comprised of whichever subset of junior residents was rotating on the inpatient service during the time period being studied. Composition of the groups fluctuated because of changes in rotation assignments. While some individuals were included in more than one of the audits, it would not have been possible to ensure the same eight residents were audited each time. This limitation represents a reality in measuring change in resident behavior after a new policy has been implemented on a specific rotation.
    The project succeeded in standardizing resident inpatient charting; the record more accurately reflected the resident’s role on the service, and residents were educated about the value of the medical record as a means of communication. It seems important to the success of the intervention that the faculty and the departmental leadership strongly supported it, and the chief residents provided some on-site feedback to junior residents about their charting practices.
    As expected, resident documentation on the inpatient unit improved immediately following education. However, gains were maintained after 6 months, and documentation of newly emphasized items continued to improve with only minimal ongoing instruction. This report shows that an educational intervention that utilizes quality improvement principles can be a useful tool for solving a residency problem and for shaping resident performance in a clinical care setting.
     
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    Figure 1.:  Data From Charts Audited at Baseline.
    1 +
    Alexander GC, Fera B, Ellic R: From the students: learning continuous improvement by doing it. Jt Comm J Qual Improv. 1996; 22:198—205
     
    2 +
    Cleghorn GD, Headrick LA: The PDSA cycle at the core of learning in health professions education. Jt Comm J Qual Improv. 1996; 22:206—212
     
    3 +
    Dankbar E: The Process for Continuous Improvement. Rochester, Minn, Mayo Foundation, 1997
     

    Figure 1.

     Data From Charts Audited at Baseline.
    +
    1 +
    Alexander GC, Fera B, Ellic R: From the students: learning continuous improvement by doing it. Jt Comm J Qual Improv. 1996; 22:198—205
     
    2 +
    Cleghorn GD, Headrick LA: The PDSA cycle at the core of learning in health professions education. Jt Comm J Qual Improv. 1996; 22:206—212
     
    3 +
    Dankbar E: The Process for Continuous Improvement. Rochester, Minn, Mayo Foundation, 1997
     
    +
    +

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