Background and objectives: Physicians frequently fail to document obesity and obesity-related counseling. We sought to determine whether attaching a physical reminder card to patient encounter forms would increase electronic medical record (EMR) assessment of and documentation of obesity and dietary counseling.
Methods: Reminder cards for obesity documentation were attached to encounter forms for patient encounters over a 2-week intervention period. For visits in the intervention period, the EMR was retrospectively reviewed for BMI, assessment of "obesity" or "morbid obesity" as an active problem, free-text dietary counseling within physician notes, and assessment of "dietary counseling" as an active problem. These data were compared to those collected through a retrospective chart review during a 2-week pre-intervention period. We also compared physician self-report of documentation via reminder cards with EMR documentation.
Results: We found significant improvement in the primary endpoint of assessment of "obesity" or "morbid obesity" as an active problem (42.5% versus 28%) compared to the pre-intervention period. There was no significant difference in the primary endpoints of free-text dietary counseling or assessment of "dietary counseling" as an active problem between the groups. Physician self-reporting of assessment of "obesity" or "morbid obesity" as an active problem (77.7% versus 42.5%), free-text dietary counseling on obesity (69.1% versus 35.4%) and assessment of "dietary counseling" as an active problem (54.3% versus 25.2%) were all significantly higher than those reflected in EMR documentation.
Conclusions: This study demonstrates that physical reminder cards are a successful means of increasing obesity documentation rates among providers but do not necessarily increase rates of obesity-related counseling or documentation of counseling. Our study suggests that even with such interventions, physicians are likely under-documenting obesity and counseling compared to self-reported rates.