by Robert Hasty, DO
Documentation in the form of the daily progress note is an important and cumbersome detail in the life of a hospitalist. Recognizing this, we saw an opportunity for improvement in this process and began a creative endeavor to rework the progress note. Our goal was to decrease the length of time that we spent on documenting redundant information such as writing out “lungs are clear to auscultation” on every patient, in order for us to focus our documentation time on more individualized information and discussion of the patients. We also wanted to simultaneously include quality improvement measures on indicators such as deep vein thrombosis (DVT) prophylaxis, urinary catheter existence, ambulation status, and nutrition. In January 2004, we instituted a template progress note for our hospital medicine service at Lee Memorial Health Systems in Lee County, FL, that has changed how we document increased DVT prophylaxis and increased our efficiency.
After some literature review, we found that evidence existed to support our initiative. Findings of several studies suggest that strategies focused on the prevention of errors of omission have utility in improving guideline compliance (1,2,3). We also found that reminders for prevention at the point of care (the progress note in our situation) were important for compliance (2–5). Furthermore, the findings of one study suggested that it was the facilitation of documentation and ordering of recommended procedures that improved guideline compliance in a small sample of resident physicians (3).
The creation of the template progress note had just begun. We knew that it would require several revisions. Therefore, we wanted to have the control of the template without needing hospital approval. To do this, we decided to use the hospital’s standard blank progress note and print the template onto the progress note using a word processing document and a laser printer. We solicited input from various members of the group for the design and required information on the template, and we reviewed previous template notes that had been utilized (although these were created for outpatient environments). We learned that having a 1-page template was important for the group. We also discovered that the hospitalists needed ample room for free writing subjective data as well as the assessment and discussion. We finally arrived at the hospitalist template progress note.
Each hospitalist was sent a copy of the template via electronic mail that could easily be printed at each nursing station. A supply of preprinted template progress notes was placed at each nursing station and maintained by our support staff. The hospitalists could also have the progress note on their personal digital assistant (PDA) and print out to the infrared enabled laser printers found throughout our institution. This option was not exercised routinely by our hospitalists.
It took a few months for the hospitalists to adapt to using the template progress notes. The initial hurdles were documentation habits and the availability of the notes at the nursing station. The documentation habits quickly changed to using the templates once the hospitalists were able to appreciate the time they saved. After 1 year of implementation, we have 100% utilization among the hospitalists at Lee Memorial Hospital (the flagship hospital of the health system). Utilization at the smaller hospitals in the system remains disappointing, likely a result of lack of template availability at the nursing stations.
An early supporter of the template progress note was Director of Case Management at Lee Memorial Health Systems Karen Harris Wise. She said, “The template progress notes are great from a case management standpoint. We can easily identify the physician, and it gives us the necessary information for our job.” Case management soon came to ask us to incorporate the estimated date of discharge at the bottom of the progress note. Once we incorporated the estimated date of discharge, the hospitalists felt they received fewer calls from case management, and the case managers were soon requesting hospitalists not using the template progress note to do so, thus improving utilization compliance.
Once implemented, the accolades and success stories for the template progress notes began flowing. Other non-hospitalist physicians at the hospital liked the idea so much that they created their own. A local pulmonologist said, “The progress note template is a great idea. It cuts out the time you waste documenting routine items and gives you more time and highlights the thoughts that you document in the discussion section.” His group later created and implemented their own template progress note specifically for ICU patients, based upon our template.
The progress note decreased the time to document each patient by approximately 42 seconds. This may not seem substantial, but multiplied by 18 patients per day (our average), this equated to over 12 minutes each day, over an hour each week, and over 60 hours a year per hospitalist.
After about 6 months of experience and success with the progress note templates, the hospital approached us to make a standardized progress note that could be used by the entire staff (Figure 1). They also wanted to incorporate Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality indicators such as smoking cessation documentation and vaccination status. We submitted our form with some modifications, and the hospital approved and published it as an official progress note template. When the hospital was inspected by JCAHO in March of 2005, it received accolades for this quality improvement tool.
This template was created with the input of our group as an initiative to have a system-wide progress note for Internal Medicine based on the success our hospitalist group had with the template progress note. (Reproduced with permission from LMHS.)
Implementing documentation of DVT prophylaxis (if applicable) was one of our original motivations for the progress note. With a check box at the top of the template note, hospitalists were faced with this documentation on every patient. We also reinforced the DVT prophylaxis with quarterly educational sessions. A DVT prophylaxis order set (Figure 2) with DVT prophylaxis indications and recommendations was also encouraged and utilized during this period of time. DVT prophylaxis compliance in our group went from less than 50% to nearly 100% during the first year of implementing the hospital progress note.
Another potential benefit may be coding compliance. Prior to implementation, we had a substantial failure rate on Medicare audits. We suspect that this number will be substantially reduced with detailed physical examination documentation built into the template, although corroborating data are not available.
Based upon our experience, a hospitalist progress note template is a promising tool with regard to time efficiency, coding compliance, and quality improvement. The electronic medical record will likely soon become the standard of inpatient documentation. The template progress note may serve as an efficient tool in the meantime and may even serve as a basis for the hospitalist electronic templates, as electronic medical records are often template based.
Robert Hasty, DO, is assistant professor of internal medicine and a hospitalist at Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, FL. Prior to his academic career, he was an associate lead hospitalist for Cogent Healthcare, Inc., at Lee Memorial Health Systems in Lee County, FL. Dr. Hasty can be contacted at email@example.com or 954-262-1473.
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