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Teaching and Maintaining Quality of Resident Inpatient Progress Notes: Development of the Progress Note Quality Instrument
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  • Carolyn Zyloney,
  • Joseph Modica,
  • Dimitrios Manou,
  • Christopher Mooney,
  • Robert Thompson-Stone
Carolyn Zyloney
Unity Hospital
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Joseph Modica
University of Rochester Medical Center
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Dimitrios Manou
University of Rochester Medical Center
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Christopher Mooney
University of Rochester Medical Center
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Robert Thompson-Stone
University of Rochester Medical Center
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Abstract

Rationale, aims and objectives: Since the widespread implementation of electronic medical records, there have been concerns about errors, excessive copying forward, and reduced quality in resident inpatient progress notes. The goal of this study was to create and validate a tool to assess the quality of progress notes written on an inpatient neurology service. Methods: A survey assessing perceptions of resident inpatient neurology progress note quality was administered to faculty and residents, and based on these results, a four item note assessment tool (PNQIv2) was developed. The tool assessed the following attributes: (1) accuracy, (2) synthesis, (3) focus, (4) patient-centeredness, and (5) copied-forward material. 120 note reviews were completed by 4 study investigators on 30 different resident progress notes utilizing 10 out of 16 possible residents (62.5%). Mean PNQIv2 scores were calculated as well as inter-rater reliability for the overall PNQIv2 scores and their subsections using inter-class correlation coefficients and 95% confidence intervals. Results: The PNQIv2 was found to have good inter-rater reliability at 0.7 and was considered quick and simple to use. The mean total PNQIv2 score was 9.2 (SD 2) out of 12. 60% of notes were determined to be at least adequate quality by receiving a PNQIv2 score of ≥ 9, and 63% of notes contained at least 2/3 copied-forward material. Conclusions: The investigators developed a progress note assessment tool that was simple and practical to use on the wards, with good inter-rater reliability, which may be useful to formally evaluate the quality of resident inpatient progress notes.