Enhancing the timeliness of EMR documentation in resident doctors: the role of PDCA cycle management.

Background: The impact of the Plan-Do-Check-Act (PDCA) cycle in improving the timeliness of electronic medical record documentation (EMRd) remains uncertain. EMRd that is completed beyond the specified time is classified as late EMRd, while unqualified EMRd refers to electronic medical records with important sections that are not completed on time according to the Chinese Basic Norms of Medical Records Writing. This study aimed to evaluate the effectiveness of PDCA management in improving the timeliness of EMRd among resident doctors.
Method: This study utilized a before and after design. Resident doctors rotating in the Head and Neck Oncology Department of West China Hospital, Sichuan University, from November 2021 to August 2022 were classified as the control group and did not receive specific training on the timeliness of EMRd. Those rotating from September 2022 to June 2023 were assigned to the PDCA group, which was managed using the PDCA cycle. The effectiveness of PDCA cycle management was evaluated by comparing the incidence of late EMRd and unqualified EMRd between two groups. Univariate and multivariate binary logistic regression analyses were conducted tocontrol for confounding factors.
Results: A total of 245 resident doctors were included, with 162 doctors in the PDCA group and 152 doctors in the control group. The incidences of late EMRd (5.40% vs. 2.56%, P = 0.005) and unqualified EMRd (1.05% vs. 0.00%, P < 0.001) were significantly lower in the PDCA group than those in the control group. After adjusting confounding factors, PDCA management still significantly reduced the occurrence of unqualified EMRd (P < 0.001) with an adjusted odds ratio (OR) of 0.166 (95% CI 0.067-0.416) and late EMRd (P < 0.001) with an adjusted OR of 0.318 (95% CI 0.181-0.557).
Conclusion: This study successfully developed PDCA management and demonstrated its effectiveness in improving the timeliness of EMRd while concurrently reducing the incidence of unqualified and late entries among resident doctors.
Competing Interests: Declarations. Ethics approval and consent to participate: Written informed consent was obtained from the individual participants or their guardians. The study was approved by the medical ethics committee of West China Hospital, Sichuan University, with the approval number 2024 − 1658. All procedures involving human participants performed in this study were in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.
(© 2024. The Author(s).)