An Evaluation of the Effectiveness of Implementing an Electronic Medical Record Documentation Tool on Documentation Rates of Patient Self-Management Goals by Primary Care Providers.

摘要

It has been well established that patients are more successful in reaching health care goals when those goals are developed collaboratively with their healthcare providers. Dr. Imogene King's theory of goal attainment specifically stresses the importance of collaborative "transactions" between providers and clients. If patient-centered, collaboratively determined self-management goals (SMGs) are not documented for consistent follow up and review, then their value is greatly reduced. The healthcare industry has made great strides in transitioning to the use of electronic health records (EHR), yet meaningful use of EHRs has not been realized. The purpose of this quality improvement (QI) project was to examine whether creating a documentation tool with improved usability for documentation of diabetic patient SMGs would result in an increased provider adherence with SMG documentation standards. Findings showed both statistically and clinically significant increases in SMG documentation rates after the QI intervention.