Orthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentation for Pediatric Supracondylar Humerus Fractures.
J Am Acad Orthop Surg
; 27(8): e395-e400, 2019 Apr 15.
Article
en En
| MEDLINE
| ID: mdl-30958425
ABSTRACT
INTRODUCTION:
Pediatric supracondylar humerus fractures are associated with a high incidence of nerve injury. Therefore, it is imperative that documentation be complete and accurate. This investigation compares orthopaedic resident history and physical (H&P) documentation of pediatric supracondylar fractures for completeness and accuracy with and without the use of an electronic medical record template.METHODS:
The electronic medical record H&P documentation of 119 supracondylar humerus fractures surgically treated at a single pediatric institution was retrospectively reviewed. Templated and nontemplated groups were compared for documentation completeness and accuracy. Definitive diagnosis of a nerve palsy was made by a supervising orthopaedic attending surgeon.RESULTS:
Forty-two cases had a templated H&P and 77 did not. The H&P documentation in the templated group was markedly more complete than that in the nontemplated group. However, the accuracy of the H&P documentation to identify nerve palsy was not statistically different between the two groups. Overall, the voluntary use of the orthopaedic template declined over time.CONCLUSION:
Resident use of an orthopaedic template for documenting the H&P of pediatric supracondylar humerus fractures compared with nontemplated notes resulted in more complete documentation but only comparable accuracy. LEVEL OF EVIDENCE III.
Texto completo:
1
Colección:
01-internacional
Base de datos:
MEDLINE
Asunto principal:
Ortopedia
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Documentación
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Registros Electrónicos de Salud
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Traumatismos de los Nervios Periféricos
/
Exactitud de los Datos
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Fracturas del Húmero
/
Internado y Residencia
Tipo de estudio:
Observational_studies
/
Prognostic_studies
/
Risk_factors_studies
Límite:
Child
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Child, preschool
/
Female
/
Humans
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Infant
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Male
Idioma:
En
Revista:
J Am Acad Orthop Surg
Asunto de la revista:
ORTOPEDIA
Año:
2019
Tipo del documento:
Article