Medical College of Wisconsin
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Improving the quality and ease of tracking invasive procedures. Med Educ 1993 Jan;27(1):86-90 PMID: 8433667

Pubmed ID



Documentation of the decision-making process leading up to an outcome of procedures is essential for assessing quality of patient care, supporting reimbursement, determination of appropriate utilization, and discernment of practitioner competence. Currently, doctors document interventions conducted outside the operating room in narratives within the daily progress notes. The free-form narrative typically includes the practitioner directly involved, procedure performed, technique used and outcomes. While hospitals encourage conformity to these documentation standards, the quality and content of the narratives vary greatly by practitioner, frequently leaving significant information missing. Therefore, to improve both quality of documentation in procedure notes and ease of monitoring non-operating room procedures, we developed a multicopy standardized procedure note. The form contains lines for recording the type, location, indication, anaesthesia, findings, and complications of the procedure, plus the persons performing, supervising and undergoing the procedure. Practitioners complete the multicopy note instead of the usual narrative note. We encode all the information from the standardized note into a data base that accumulates information on all procedures done throughout the hospital. The data base is used to generate summary reports to provide feedback to residents, residency directors and practitioners on procedural proficiency. The major advantage of this system is that it simultaneously improves the quality of documentation and ease of tracking non-operating room procedures at our hospitals. In addition, the system collects the information needed for reimbursement coding, hospital quality assurance and utilization review, and practitioner and resident credentialling purposes.

Author List

Van Ruiswyk J, Erdmann M


Jerome V. Van Ruiswyk MD Professor in the Medicine department at Medical College of Wisconsin


2-s2.0-0027526398   1 Citations

MESH terms used to index this publication - Major topics in bold

Clinical Competence
Data Collection
Decision Making
Medical Records
Quality of Health Care
jenkins-FCD Prod-353 9ccd8489072cb19f5b9f808bb23ed672c582f41e