TY - JOUR
T1 - Impact of a palliative care checklist on clinical documentation
AU - De La Cruz, Maxine
AU - Reddy, Akhila
AU - Vidal, Marieberta
AU - Tanco, Kimberson
AU - Azhar, Ahsan
AU - Silvestre, Julio
AU - Liu, Diane D.
AU - Wu, Jimin
AU - Bruera, Eduardo
N1 - Publisher Copyright:
© 2016 by American Society of Clinical Oncology.
PY - 2016/2
Y1 - 2016/2
N2 - Purpose Checklistsareusedinmanydifferentsettingsforthepurposeofstandardizationandreduction of preventable errors in practice. Our group sought to determine whether a palliative care checklist (PCC) would improve the clinical documentation of key patient information. Methods An initial review of 110 randomly selected medical records dictated by 10 physicians was performed. The authors identified portions of the dictated medical records that were included regularly, as well as those that were frequently missed. A PCC was drafted after final approval was obtained from the 13 faculty members. Dictations from 13 clinical faculties in the supportive care center were reviewed. A 2 test or Fisher's exact test was applied to assess the difference in overall checked rates before and after checklist use. A paired t test was used to examine the difference in the average complete rate and checked rates before and after checklist use. Results There were improvements in the documentation before and after the checklist for scores on the Cut-down, Annoyed, Guilty, Eye-opener questionnaire for alcoholism (79% v 94%; P <.0001), psychosocial history (69% v 95%; P <.0001), Eastern Cooperative Oncology Group performance status (38% v 81%; P<.0001), advance care planning (28% v 41%; P =.0008), and overall (78% v 95%; P <.0001). There was no significant improvement in the documentation for opioid-induced neurotoxicity (37% v 37%; P =.9492) or the Edmonton Symptom Assessment Scale (98% v 99%; P =.4511). Conclusion Our study showed that the use of a PCC improved the quality of the documentation of a patient visit in an outpatient clinical setting.
AB - Purpose Checklistsareusedinmanydifferentsettingsforthepurposeofstandardizationandreduction of preventable errors in practice. Our group sought to determine whether a palliative care checklist (PCC) would improve the clinical documentation of key patient information. Methods An initial review of 110 randomly selected medical records dictated by 10 physicians was performed. The authors identified portions of the dictated medical records that were included regularly, as well as those that were frequently missed. A PCC was drafted after final approval was obtained from the 13 faculty members. Dictations from 13 clinical faculties in the supportive care center were reviewed. A 2 test or Fisher's exact test was applied to assess the difference in overall checked rates before and after checklist use. A paired t test was used to examine the difference in the average complete rate and checked rates before and after checklist use. Results There were improvements in the documentation before and after the checklist for scores on the Cut-down, Annoyed, Guilty, Eye-opener questionnaire for alcoholism (79% v 94%; P <.0001), psychosocial history (69% v 95%; P <.0001), Eastern Cooperative Oncology Group performance status (38% v 81%; P<.0001), advance care planning (28% v 41%; P =.0008), and overall (78% v 95%; P <.0001). There was no significant improvement in the documentation for opioid-induced neurotoxicity (37% v 37%; P =.9492) or the Edmonton Symptom Assessment Scale (98% v 99%; P =.4511). Conclusion Our study showed that the use of a PCC improved the quality of the documentation of a patient visit in an outpatient clinical setting.
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U2 - 10.1200/JOP.2015.007203
DO - 10.1200/JOP.2015.007203
M3 - Article
C2 - 26733626
AN - SCOPUS:84958257990
SN - 1554-7477
VL - 12
SP - e241-e247
JO - Journal of oncology practice
JF - Journal of oncology practice
IS - 2
ER -