More Time for Doctoring: Reduction of Resident Daily Documentation Burden. (16th November 2020)

• Record Type: Journal Article
• Authors: Hunt, Rachel J; Fletcher, Shelley; Rock, Jack P; Air, Ellen L
• Is Part Of: Neurosurgery. Volume 67(2010)Supplement 1
• Publication Date: 2020-11-16
• Subjects: Nervous system -- Surgery -- Periodicals; 617.48005
• DOI: 10.1093/neuros/nyaa447_197
• Languages: English
• ISSNs: 0148-396X

Abstract

Abstract: INTRODUCTION: The introduction of the electronic medical record (EMR) has significantly changed physician workflow. Staying late to finish notes is the norm, and the documentation burden imposed by EMR has been cited as a significant factor in physician burnout. Junior surgical residents in some institutions have been reported to spend as much as 30% of their time on chart review and documentation. METHODS: The neurosurgery written handoff, previously designed by the Henry Ford neurosurgery residents to improve communication during patient handoff, was reviewed with medical coders. With minor alterations to the template, the information contained in the written handoff was determined to be sufficient for billing requirements. The written handoff was then filed as the daily physician progress note in lieu of the traditional SOAP note. After one year, the incidence of coding queries and missed billing opportunities were audited to ensure that billing was not negatively impacted. RESULTS: The integrated progress note/handoff format was implemented in February of 2019. Because maintaining a written handoff was already vital to team workflow, the integrated note/handoff format essentially removed the busywork of writing daily progress notes. Residents unanimously reported a decrease in time spent on documentation. Progress note-related coding queries decreased by 44%. Missed billing opportunities due to insufficient documentation decreased by 67%. There was no change in the incidence of coding queries related to other forms of documentation. CONCLUSION: Integration of a written handoff with physician daily progress note decreased physician documentation burden while simultaneously improving note usability for billing. Prior studies have shown that the use of standardized written handoff significantly reduces medical errors. Combining the concept of the physician progress note with a written handoff has the potential to improve patient care while simulataneously providing junior neurosurgery residents with more time to spend honing their operative skills.