Date of Award

Spring 2024

Document Type

DNP Project

Project Team Faculty Member

Ashley Wittler

Project Team Faculty Member

Annie Imboden

Keywords

Template, depression, anxiety, ADHD, concussion, guideline, electronic health record, pediatric

Abstract

Evidence-based clinic guidelines improve patient outcomes by providing clinicians with research-based recommendations, and when combined with the electronic health record (EHR), clinicians have the potential to improve their documentation and reduce the time it takes to document a patient encounter. A pediatric clinic in the metro-east area of Southern Illinois lacked EHR templates during patient encounters that focused on depression, anxiety, ADHD, and concussion screening. Templates embedded in the EHR were created in a SOAP note format to aid the clinicians during patient encounters and aid in documentation. Clinicians were asked to utilize the templates over a 6-week period. The intervention was evaluated before and after the implementation. Post-implementation note quality and documentation time improved by 33% after implementing the intervention. Documentation also showed a 20% increase in thoroughness and organization. A multiple-choice survey was also used to determine the provider’s current knowledge of the diagnoses and patient population being treated for depression, anxiety, ADHD, and concussions. There were many limitations in this study, including a lack of provider buy-in, limited sample size, and limited patient encounters. A larger provider buy-in and sample size would better represent the effectiveness of the templates in practice.

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