Skip to main content

Main menu

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
Meeting ReportWomen’s health

The Use of a Structured Documentation to Improve Adherence to Clinical Guidelines

Samuel Ofei-Dodoo, Mary Masterman, Rachel Griffith, Emily Manlove and Matthew Hoang
The Annals of Family Medicine November 2023, 21 (Supplement 3) 4727; DOI: https://doi.org/10.1370/afm.22.s1.4727
Samuel Ofei-Dodoo
PhD, MA, MPA, CPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mary Masterman
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Rachel Griffith
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Emily Manlove
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Matthew Hoang
BS
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • eLetters
  • Info & Metrics
  • PDF
Loading

Abstract

Introduction. Research has shown that structured documentation, like prepopulated “dot phrases,” can improve quality measures when compared to free text or dictation. This has been attributed to clinicians interacting more with the electronic health record (her), pre-populated clinical decision support, and increased speed of documentation. However, clinicians reported less satisfaction with this method, with redundant notes and excessive copy and paste. The study evaluated the utility of an initial obstetrical (IOB) structured documentation to prompt physicians to appropriately recommend aspirin for preeclampsia prevention and to improve compliance with clinical guidelines.

Methods. The study was conducted at two local clinics, which used an updated “dot phrase” for IOB visits, with the updated USPSTF recommendations on aspirin use in pregnancy. We reviewed data on patients with their IOB appointment, pre-, post-, and 6-months following implementation of the dot phrase. 306 charts were reviewed by two groups of two reviewers during the study period. The current ACOG guidelines for assessing pre-eclampsia risk were used in determining risk and appropriate aspirin usage. Cohen’s kappa coefficient (κ) measured the reviewers’ inter-rater agreement for the charts reviewed. Authors used standard descriptive statistics to calculate the number of OB patients at risk for pre-eclampsia and those who received aspirin. We used cumulative risk, rate ratio, and percentage relative effect to determine if structured documentation prompted appropriate aspirin use.

Results. The Cohen’s κ calculation showed agreement between the two groups of raters, κ=.908 (95% CI, 0.84 to 0.98), P<.0001. 103 IOB visits occurred prior to the intervention. 59 patients were at risk of preeclampsia, 11 (17%) were recommended aspirin. 102 IOB visits occurred after the intervention. 43 patients were at risk for pre-eclampsia, 34 (79%) were recommended aspirin. 101 IOB visits occurred 6-month after the intervention. 42 patients were at risk for pre-eclampsia, 39 (93%) were recommended aspirin.

Conclusion. Our data showed that IOB structured documentation improved the appropriate use of aspirin for pre-eclampsia prevention and patient care. Overall, the findings of this study suggest that structured documentation is an effective tool in improving clinical practice and patient outcomes. Future studies should address clinician dissatisfaction with redundancy with the structured documentation.

  • © 2023 Annals of Family Medicine, Inc.
Previous
Back to top

In this issue

The Annals of Family Medicine: 21 (Supplement 3)
The Annals of Family Medicine: 21 (Supplement 3)
Vol. 21, Issue Supplement 3
1 Nov 2023
  • Table of Contents
  • Index by author
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
The Use of a Structured Documentation to Improve Adherence to Clinical Guidelines
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
3 + 0 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
The Use of a Structured Documentation to Improve Adherence to Clinical Guidelines
Samuel Ofei-Dodoo, Mary Masterman, Rachel Griffith, Emily Manlove, Matthew Hoang
The Annals of Family Medicine Nov 2023, 21 (Supplement 3) 4727; DOI: 10.1370/afm.22.s1.4727

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
The Use of a Structured Documentation to Improve Adherence to Clinical Guidelines
Samuel Ofei-Dodoo, Mary Masterman, Rachel Griffith, Emily Manlove, Matthew Hoang
The Annals of Family Medicine Nov 2023, 21 (Supplement 3) 4727; DOI: 10.1370/afm.22.s1.4727
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Pregnancy outcomes and complications in refugees and other newcomers at a Family Medicine practice in Philadelphia, PA
  • Is Rural Residence a Risk Factor for Preterm Birth in Iowa?
  • Influence of social determinants of health and emotional health factors on female sexual health
Show more Women’s health

Similar Articles

Content

  • Current Issue
  • Past Issues
  • Early Access
  • Plain-Language Summaries
  • Multimedia
  • Podcast
  • Articles by Type
  • Articles by Subject
  • Supplements
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Job Seekers
  • Media

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2025 Annals of Family Medicine