Use of a structured encounter form to improve well-child care documentation

Arch Fam Med. Sep-Oct 1998;7(5):480-3. doi: 10.1001/archfami.7.5.480.

Abstract

Objective: To determine if a structured encounter form for well-child care improves documentation of well-child care.

Design: Retrospective medical record review of a before-and-after trial.

Setting: Family practice residency clinic serving a primarily low-socioeconomic urban population.

Patients: Children younger than 6 years receiving well-child care visits.

Intervention: Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force.

Main outcome measures: Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form.

Results: A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form.

Conclusions: The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child
  • Child Health Services / organization & administration*
  • Child Health Services / standards
  • Documentation / standards
  • Family Practice / education
  • Family Practice / organization & administration
  • Forms and Records Control
  • Humans
  • Internship and Residency
  • Medical Records / standards*
  • Minnesota
  • Outpatient Clinics, Hospital
  • Preventive Health Services / organization & administration*
  • Preventive Health Services / standards
  • Retrospective Studies
  • Surveys and Questionnaires
  • Urban Population