BACKGROUND: Age-specific structured encounter forms for well-child examinations have been shown to improve thoroughness of documentation among pediatric house staff. This study evaluated the influence of such forms on completeness of documentation by practicing pediatricians. METHODS: In this before-after trial at 5 urban community health clinics, participants were 8 pediatricians practicing for at least 1 year. Brief group training sessions on use of the forms were provided to the participating physicians. Completeness of documentation was defined as the proportion of elements from a full well-child examination recorded in the medical record. RESULTS: After introduction of the standardized forms, completeness of documentation significantly increased for all components. CONCLUSIONS: The use of age-specific structured encounter forms improved the completeness of documentation of pediatric well-child examinations done by pediatricians.
BACKGROUND: Age-specific structured encounter forms for well-child examinations have been shown to improve thoroughness of documentation among pediatric house staff. This study evaluated the influence of such forms on completeness of documentation by practicing pediatricians. METHODS: In this before-after trial at 5 urban community health clinics, participants were 8 pediatricians practicing for at least 1 year. Brief group training sessions on use of the forms were provided to the participating physicians. Completeness of documentation was defined as the proportion of elements from a full well-child examination recorded in the medical record. RESULTS: After introduction of the standardized forms, completeness of documentation significantly increased for all components. CONCLUSIONS: The use of age-specific structured encounter forms improved the completeness of documentation of pediatric well-child examinations done by pediatricians.
Authors: David Gathara; Newton Opiyo; John Wagai; Stephen Ntoburi; Philip Ayieko; Charles Opondo; Annah Wamae; Santau Migiro; Wycliffe Mogoa; Aggrey Wasunna; Fred Were; Grace Irimu; Mike English Journal: BMC Health Serv Res Date: 2011-11-11 Impact factor: 2.655