• Maxine de la Cruz, Akhila Reddy, Marieberta Vidal, Kimberson Tanco, Ahsan Azhar, Julio Silvestre, Diane D Liu, Jimin Wu, and Eduardo Bruera.
• The University of Texas MD Anderson Cancer Center, Houston, TX and University of Virginia Health System, Charlottesville, VA mdelacruz@mdanderson.org.
• J Oncol Pract. 2016 Feb 1; 12 (2): e241-7.

PurposeChecklists are used in many different settings for the purpose of standardization and reduction of preventable errors in practice. Our group sought to determine whether a palliative care checklist (PCC) would improve the clinical documentation of key patient information.MethodsAn initial review of 110 randomly selected medical records dictated by 10 physicians was performed. The authors identified portions of the dictated medical records that were included regularly, as well as those that were frequently missed. A PCC was drafted after final approval was obtained from the 13 faculty members. Dictations from 13 clinical faculties in the supportive care center were reviewed. A χ(2) test or Fisher's exact test was applied to assess the difference in overall checked rates before and after checklist use. A paired t test was used to examine the difference in the average complete rate and checked rates before and after checklist use.ResultsThere were improvements in the documentation before and after the checklist for scores on the Cut-down, Annoyed, Guilty, Eye-opener questionnaire for alcoholism (79% v 94%; P ≤ .0001), psychosocial history (69% v 95%; P ≤ .0001), Eastern Cooperative Oncology Group performance status (38% v 81%; P ≤ .0001), advance care planning (28% v 41%; P = .0008), and overall (78% v 95%; P ≤ .0001). There was no significant improvement in the documentation for opioid-induced neurotoxicity (37% v 37%; P = .9492) or the Edmonton Symptom Assessment Scale (98% v 99%; P = .4511).ConclusionOur study showed that the use of a PCC improved the quality of the documentation of a patient visit in an outpatient clinical setting.Copyright © 2016 by American Society of Clinical Oncology.

13 keywords...

hide…