North Texas GME Research Forum 2024

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Division

North Texas

Hospital

Medical City Arlington

Specialty

Family Medicine

Document Type

Poster

Publication Date

2024

Keywords

quality improvement, exercise

Disciplines

Family Medicine | Medicine and Health Sciences | Quality Improvement

Abstract

Background: There is vast data on the health benefits of physical activity (PA) and the serious health consequences that are associated with a sedentary lifestyle. Research suggests that physicians who have meaningful conversations about exercise with their patients can be effective at increasing their patients' PA. In order to measure the effects of these discussions, the clinician must be able to document the baseline and subsequent PA of their patients. Our project seeks to improve the assessment and documentation of patient PA. Methods: Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team was created to identify ways to improve documentation of patients' PA in the EMR. The team reviewed current policies and guidelines of PA documentation. Educational resources and training sessions were provided for clinic residents to appropriately ask and document PA. Comparison of pre-intervention and post-intervention adherence to charting recommendations was performed. Pre-intervention patients included a review of Medical City Grand Prairie Family Medicine patient records to identify PA documentation rates under the social history section of the patient encounter. Post-intervention patients beginning January 1, 2024 were identified in a similar manner, and documentation rates were analyzed at the 1, 2, and 3 month marks, respectively. Documentation and education reminders were regularly given to clinic staff before clinic began each day. Results: Appropriate documentation improved to x% in months 1,2, and 3, respectively, from a pre-intervention baseline rate of y%. Pre-interventionally, a% of patients were documented in social history as not exercising at all, b% of patients exercised moderately, and c% of patients exercised regularly. Post-intervention, these improved to d%, e%, and f% of no, moderate, and regular exercise, respectively. All documentation was reviewed by the residents performing the research. Conclusions: Promoting the questioning and documentation of a patient's PA can increase/decrease/have no effect on the EMR documentation rates at a primary care clinic. More promotion and education will be needed in the future to continue to identify patient populations with deficient amounts of physical activity, and assess responses to different exercise prescription (ExRx) interventions.

Original Publisher

HCA Healthcare Graduate Medical Education

Improving Documentation of Patients' Physical Activity in the Outpatient Setting

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