Documentation Optimization in Clinical Emergency Medicine ( <scp>DOC</scp> ‐ <scp>EM</scp> )

ABSTRACT Background High‐quality documentation is essential to patient care, billing accuracy, medicolegal protection, and effective communication in emergency medicine. Despite its importance, documentation training in graduate medical education remains inconsistent and infrequently assessed. Precision education, a model that tailors instruction to individual performance using real‐time data, offers an opportunity to address this gap. Objectives The objective of this study was to evaluate whether personalized, data‐driven feedback derived from electronic health record (EHR) usage metrics improves emergency medicine (EM) residents' documentation timeliness and self‐reported efficiency. Curricular Design We conducted a prospective educational intervention at a single academic EM residency program from February 2024 to June 2025. Epic's Provider Efficiency Profile (PEP) reports, summarizing EHR usage metrics such as note length, time to completion, SmartPhrase utilization, and dictation frequency, were distributed quarterly. Documentation data from a single Level 1 trauma center site were analyzed. The first PEP served as a baseline; subsequent reports were paired with individualized, behavior‐specific feedback delivered by an Assistant Program Director. Pre‐ and postintervention data were compared for changes in note completion time, and residents completed postintervention surveys assessing perceived impact on efficiency and workflow. Results Fifty‐eight residents contributed 199 records for analysis. The proportion of notes completed before patient departure decreased slightly from 67% to 61% ( p &lt; 0.01), while completion within 12 h improved from 23% to 27% ( p = 0.04). Most residents (83%) reported improved documentation efficiency, and 78% reported changing one or more on‐shift habits. The program was well received (mean satisfaction score 8.9/10). Conclusions Implementation of the DOC‐EM curriculum was feasible and associated with modest improvements in timely documentation and perceived efficiency. Precision education frameworks leveraging EHR‐derived data may represent a scalable, adaptable strategy for improving resident documentation practices, even in institutions with limited informatics support.

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Publication Details

Journal
AEM Education and Training
Published
2026-03-16
DOI
https://doi.org/10.1002/aet2.70151
Primary Topic
Electronic Health Records Systems
Type
article
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article

Documentation Optimization in Clinical Emergency Medicine ( DOC ‐ EM )

Jessica Baéz, Meaghan K Frederick, Heidi Sucharew
AEM Education and Training
Electronic Health Records Systems
article

Documentation Optimization in Clinical Emergency Medicine ( DOC ‐ EM )

Jessica Baéz, Meaghan K Frederick, Heidi Sucharew
article en

Abstract

ABSTRACT Background High‐quality documentation is essential to patient care, billing accuracy, medicolegal protection, and effective communication in emergency medicine. Despite its importance, documentation training in graduate medical education remains inconsistent and infrequently assessed. Precision education, a model that tailors instruction to individual performance using real‐time data, offers an opportunity to address this gap. Objectives The objective of this study was to evaluate whether personalized, data‐driven feedback derived from electronic health record (EHR) usage metrics improves emergency medicine (EM) residents' documentation timeliness and self‐reported efficiency. Curricular Design We conducted a prospective educational intervention at a single academic EM residency program from February 2024 to June 2025. Epic's Provider Efficiency Profile (PEP) reports, summarizing EHR usage metrics such as note length, time to completion, SmartPhrase utilization, and dictation frequency, were distributed quarterly. Documentation data from a single Level 1 trauma center site were analyzed. The first PEP served as a baseline; subsequent reports were paired with individualized, behavior‐specific feedback delivered by an Assistant Program Director. Pre‐ and postintervention data were compared for changes in note completion time, and residents completed postintervention surveys assessing perceived impact on efficiency and workflow. Results Fifty‐eight residents contributed 199 records for analysis. The proportion of notes completed before patient departure decreased slightly from 67% to 61% ( p &lt; 0.01), while completion within 12 h improved from 23% to 27% ( p = 0.04). Most residents (83%) reported improved documentation efficiency, and 78% reported changing one or more on‐shift habits. The program was well received (mean satisfaction score 8.9/10). Conclusions Implementation of the DOC‐EM curriculum was feasible and associated with modest improvements in timely documentation and perceived efficiency. Precision education frameworks leveraging EHR‐derived data may represent a scalable, adaptable strategy for improving resident documentation practices, even in institutions with limited informatics support.

AEM Education and TrainingVol. 10(2)
University of Cincinnati (US)
Quality Education
Openalex Percentile: Top 18%
Electronic Health Records Systems
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