Orthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentattion for Pediatric Supracondylar Humerus Fractures
- Resource Type
- Academic Journal
- Authors
- Urchek, Ryan J.; Morscher, Melanie A.; Steiner, Richard P.; Adamczyk, Mark J.
- Source
- Journal of the American Academy of Orthopaedic Surgeons. Oct 02, 2018
- Subject
- Language
- English
- ISSN
- 1067-151X
INTRODUCTION:: Pediatric supracondylar humerus fractures are associated with a high incidence of nerve injury. Therefore, it is imperative that documentation be complete and accurate. This investigation compares orthopaedic resident history and physical (H&P) documentation of pediatric supracondylar fractures for completeness and accuracy with and without the use of an electronic medical record template. METHODS:: The electronic medical record H&P documentation of 119 supracondylar humerus fractures surgically treated at a single pediatric institution was retrospectively reviewed. Templated and nontemplated groups were compared for documentation completeness and accuracy. Definitive diagnosis of a nerve palsy was made by a supervising orthopaedic attending surgeon. RESULTS:: Forty-two cases had a templated H&P and 77 did not. The H&P documentation in the templated group was markedly more complete than that in the nontemplated group. However, the accuracy of the H&P documentation to identify nerve palsy was not statistically different between the two groups. Overall, the voluntary use of the orthopaedic template declined over time. CONCLUSION:: Resident use of an orthopaedic template for documenting the H&P of pediatric supracondylar humerus fractures compared with nontemplated notes resulted in more complete documentation but only comparable accuracy. LEVEL OF EVIDENCE:: III