Orthopaedic Resident Use of an Electronic Medical Record Template Does Not Improve Documentation for Pediatric Supracondylar Humerus Fractures.

Abstract

Pediatric supracondylar humerus fractures are associated with a high incidence of nerve injury. Therefore, it is imperative that documentation be complete and accurate. This investigation compares orthopaedic resident history and physical (H&P) documentation of pediatric supracondylar fractures for completeness and accuracy with and without the use of an electronic medical record template. The electronic medical record H&P documentation of 119 supracondylar humerus fractures surgically treated at a single pediatric institution was retrospectively reviewed. Templated and nontemplated groups were compared for documentation completeness and accuracy. Definitive diagnosis of a nerve palsy was made by a supervising orthopaedic attending surgeon. Forty-two cases had a templated H&P and 77 did not. The H&P documentation in the templated group was markedly more complete than that in the nontemplated group. However, the accuracy of the H&P documentation to identify nerve palsy was not statistically different between the two groups. Overall, the voluntary use of the orthopaedic template declined over time. Resident use of an orthopaedic template for documenting the H&P of pediatric supracondylar humerus fractures compared with nontemplated notes resulted in more complete documentation but only comparable accuracy. III.