Structured encounter form: The impact on provider performance and recording of well-child care

A. K. Duggan, B. Starfield, C. DeAngelis

Research output: Contribution to journalArticlepeer-review

Abstract

The impact of record format on provider performance and recording of the process of care and their concordance were examined in this study. The process of care was defined by existing sets of explicit criteria developed for quality assessment. The study was conducted in an urban teaching hospital pediatric primary care clinic. Housestaff were encouraged, but not required, to use the clinic's structured, age-specific forms for recording well-child care. Performance and recording were compared during required well-child visits using the structured form and those using the basic clinic form. Study data from 1031 visits to 68 housestaff during a 14-month period were collected using medical record abstracting of all visits and direct observation of 243 of them. Twenty-three of the providers were assigned randomly to an unobserved control group to assess the effect of observation on recording. Use of the structured form was associated with significantly higher levels of both recorded and observed performance. When performance could be merely checked off to document performance, overdocumentation was found. Record-based estimates of performance were more accurate during visits when the structured form was used. Record format can improve provider performance and recording of the process of care.

Original languageEnglish (US)
Pages (from-to)104-113
Number of pages10
JournalPediatrics
Volume85
Issue number1
StatePublished - Jan 1 1990

Keywords

  • ambulatory care
  • medical care quality
  • medical education
  • medical records

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Fingerprint

Dive into the research topics of 'Structured encounter form: The impact on provider performance and recording of well-child care'. Together they form a unique fingerprint.

Cite this