ArticleApplied clinical informatics2022
Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program.
Article in Applied clinical informatics, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers, 2 of them syntheses that pooled it.
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Who cites it
12 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Factors associated with inpatient medical record data quality in hospital settings: a systematic review.BMC health services research · 2026Pooled it
- Challenges for Data Quality in the Clinical Data Life Cycle: Systematic Review.Journal of medical Internet research · 2025Pooled it
- Time Burden of Electronic Medical Records on Nurses and Physicians in Saudi Arabia: Occurrence, Predictors, and Challenges-A Mixed-Methods Study.Healthcare (Basel, Switzerland) · 2026Article
- A nursing perspective on human-AI collaboration in personalized breast cancer care pathways.Frontiers in oncology · 2026Article
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- Introducing a New Investigation Sheet at Almanagil Teaching Hospital in Sudan: A Quality Improvement Project.Cureus · 2025Article
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- A Quality Improvement Intervention to Enhance Documentation on Histopathology Request Forms.Cureus · 2025Article
- Pre-diagnosis and pre-treatment loss to follow-up and associated factors among patients with presumed tuberculosis and those diagnosed in Uganda.BMC health services research · 2024Article
- Workflow Improvement of Electronic Health Record Usage in a Tertiary Pediatric Burns Clinic.Applied clinical informatics · 2023Observational
Corrections and comments
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Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundIntroducing an electronic medical record (EMR) system into a complex health care environment fundamentally changes clinical workflows and documentation processes and, hence, has implications for patient safety. After a multisite "big-bang" EMR implementation across our large public health care organization, a quality improvement program was developed and implemented to monitor clinician adoption, documentation quality, and compliance with workflows to support high-quality patient care.
objectiveOur objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation.
methodsThe Model for Improvement quality improvement framework guided cycles of "Plan, Do, Study, Act." Steps included design, pre- and pilot testing of an audit tool to reflect expected practices for EMR documentation that examined quality and completeness of documentation 1-year post-EMR implementation. Analysis of initial audit results was then performed to (1) provide a baseline to benchmark comparison of ongoing improvement and (2) develop targeted intervention activities to address identified gaps.
resultsAnalysis of 1,349 EMR record audits as a baseline for the first cycle of EMR quality improvement revealed five out of nine nursing and midwifery documentation components, and four out of ten medical documentation components' completion and quality were classified as good (>80%). Outputs from this work also included a framework for strategies to improve EMR documentation quality, as well as an EMR data dashboard to monitor compliance.
conclusionThis work provides the foundation for the development of quality monitoring frameworks to inform both clinician and EMR optimization interventions using audits and feedback. Discipline-specific differences in performance can inform targeted interventions to maximize the effective use of resources and support longitudinal monitoring of EMR documentation and workflows. Future work will include repeat EMR auditing.
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