{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,10]],"date-time":"2026-01-10T08:11:06Z","timestamp":1768032666732,"version":"3.49.0"},"reference-count":13,"publisher":"Georg Thieme Verlag KG","issue":"03","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Appl Clin Inform"],"published-print":{"date-parts":[[2016,7]]},"abstract":"<jats:title>Summary<\/jats:title><jats:p>Communication errors are identified as a root cause contributing to a majority of sentinel events. The clinical note is a cornerstone of physician communication, yet there are few published interventions on teaching note writing in the electronic health record (EHR). This is a prospective, two-site, quality improvement project to assess and improve the quality of clinical documentation in the EHR using a validated assessment tool.<\/jats:p><jats:p>Internal Medicine (IM) residents at the University of Kentucky College of Medicine (UK) and Montefiore Medical Center\/Albert Einstein College of Medicine (MMC) received one of two interventions during an inpatient ward month: either a lecture, or a lecture and individual feedback on progress notes. A third group of residents in each program served as control. Notes were evaluated with the Physician Documentation Quality Instrument 9 (PDQI-9).<\/jats:p><jats:p>Due to a significant difference in baseline PDQI-9 scores at MMC, the sites were not combined. Of 75 residents at the UK site, 22 were eligible, 20 (91%) enrolled, 76 notes in total were scored. Of 156 residents at MMC, 22 were eligible, 18 (82%) enrolled, 40 notes in total were scored. Note quality did not improve as measured by the PDQI-9.<\/jats:p><jats:p>This educational quality improvement project did not improve the quality of clinical documentation as measured by the PDQI-9. This project underscores the difficulty in improving note quality. Further efforts should explore more effective educational tools to improve the quality of clinical documentation in the EHR.<\/jats:p><jats:p>\n            Citation: Fanucchi L, Yan D, Conigliaro RL. Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record.<\/jats:p>","DOI":"10.4338\/aci-2016-02-cr-0025","type":"journal-article","created":{"date-parts":[[2016,7,6]],"date-time":"2016-07-06T08:26:15Z","timestamp":1467793575000},"page":"653-659","source":"Crossref","is-referenced-by-count":12,"title":["Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record"],"prefix":"10.4338","volume":"07","author":[{"given":"Donglin","family":"Yan","sequence":"first","affiliation":[]},{"given":"Rosemarie","family":"Conigliaro","sequence":"first","affiliation":[]},{"given":"Laura","family":"Fanucchi","sequence":"additional","affiliation":[]}],"member":"194","published-online":{"date-parts":[[2017,12,19]]},"reference":[{"key":"10.4338\/ACI-2016-02-CR-0025-1","doi-asserted-by":"publisher","DOI":"10.1097\/CCM.0b013e3182711a1c"},{"key":"10.4338\/ACI-2016-02-CR-0025-2","doi-asserted-by":"publisher","DOI":"10.1080\/10401334.2013.857337"},{"key":"10.4338\/ACI-2016-02-CR-0025-3","doi-asserted-by":"publisher","DOI":"10.1378\/chest.13-0886"},{"key":"10.4338\/ACI-2016-02-CR-0025-4","unstructured":"Sentinel Event Data - Root Causes by Event Type. 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