Improved documentation of wound care with a structured encounter form in the pediatric emergency department

Ambul Pediatr. 2005 Jul-Aug;5(4):253-7. doi: 10.1367/A04-196R.1.


Objective: Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital.

Methods: The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care.

Results: Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting.

Discussion: In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.

Publication types

  • Evaluation Study

MeSH terms

  • California
  • Child
  • Documentation / methods
  • Documentation / standards*
  • Emergency Service, Hospital / organization & administration
  • Emergency Service, Hospital / standards*
  • Forms and Records Control / methods*
  • Hospitals, Pediatric
  • Hospitals, Teaching
  • Humans
  • Internship and Residency
  • Medical Records, Problem-Oriented*
  • Medical Staff, Hospital
  • Nurse Practitioners
  • Patient Care Team / standards
  • Process Assessment, Health Care
  • Prospective Studies
  • Total Quality Management / methods*
  • Wounds and Injuries / diagnosis
  • Wounds and Injuries / therapy*