Standardized Note Template Expedites Completion of Consults for Surgical Fetal Anomalies.

Abstract

Introduction: We developed standardized electronic medical record templates (EMR-temp) for use in ambulatory prenatal surgical consultations for surgical fetal anomalies (SFAs). Our aim was to evaluate EMR-temp impact in provider documentation in prenatal care of SFA.

Methods: Prenatal consultations for SFAs at a single institution were retrospectively reviewed (2019-2022). Disease-specific EMR-templates were developed. Note content and time to encounter closure (TEC) were collected. Descriptive statistics, chi-square, Fisher's Exact Test, and Wilcoxon rank sum tests were used.

Results: Seven hundred twenty-four prenatal consultations were analyzed, with 131 consultations (18%) using EMR-temp for 55 (42%) congenital diaphragmatic hernia, 50 (38%) congenital lung malformations, 9 (7%) neural tube defects, 8 (6%) gastroschisis, and 9 (7%) heterotaxy. Overall median TEC was 23.9 hs [interquartile range (IQR) 1.3-128.6]. EMR-temp use decreases TEC from 28.4 hs [IQR 1.6-159.4] to 2.07 hs [IQR 0.85-76.2] (P < 0.001). The impact of EMR-temp varies depending on pathology. In congenital diaphragmatic hernia, EMR-temp decreased TEC 61%, from 52.0 [IQR 2.6-171.1] to 20.3 hs [IQR 1.5-55.5] (P = 0.01). In neural tube defect, EMR-temp decreased TEC 98% from 48.6 [IQR 2.6-157.1] to 1.02 hs [IQR 0.5-1.5] (P < 0.001). There were no differences in TEC with EMR-temp use in congenital lung malformation, gastroschisis and heterotaxy (P > 0.05). Across all diseases, EMR-temp had more comprehensive documentation of the following content: pathophysiology (92%), pregnancy planning (92%), delivery planning (84%), postnatal planning (95%), and long-term follow-up (90%) compared to nontemplates (P < 0.01).

Conclusions: EMR templates in SFA consultations improves encounter closure with comprehensive documentation of disease-specific pathophysiology and plans. However, impact varies across pathology, suggesting other factors are also important.