Primary Faculty Mentor Name

Marianne R. Orest, PT MEd

Project Collaborators

"Jill N. McDougall PT, DPT" "Ann C. Greenan-Naumann PT, MS, OCS" "Wendy D. King, PT"

Secondary Mentor NetID

shenry

Secondary Mentor Name

Sharon M. Henry, PT, PhD

Status

Undergraduate

Student College

College of Arts and Sciences

Program/Major

Biology

Primary Research Category

Health Sciences

Presentation Title

Clinician Adherence to Documentation Standards and Functional Outcomes for Patients with Total Knee Arthroplasty

Time

9:00 AM

Location

Silver Maple Ballroom - Health Sciences

Abstract

Background

Total knee arthroplasty (TKA) is a common procedure performed on over 600,000 patients with chronic osteoarthritis each year. The rehabilitation for TKA involves extensive physical therapy for adequate recovery (Losina et al., 2016). A standard of care regarding outcome measures for this patient population was not established at The University of Vermont Medical Center. The outpatient physical therapists developed a standard set of outcome measures for patients with TKA that assessed patient progress.

Objective

The objective of this quality improvement project was to evaluate: 1) clinician adherence to documentation standards and 2) patient functional outcomes by using four outcome measures (30 Second Chair Stand, Gait Speed, Timed Up and Go, and Single Limb Stance Test).

Methods

Audits were completed for 32 patients with TKA who received physical therapy services from October 2017 through March 2018 and from June 2018 through September 2018. The data were extracted manually and recorded in an Excel spreadsheet. Clinician adherence to documentation standards was examined by counting the instances of outcome measure scores entered in the flowsheet, approved smart phrases used, and clinically relevant documentation. Patient outcomes included the achievement of established goals as reflected by the outcome measures.

Results

The preliminary results showed that clinicians increased their adherence to clinical documentation standards from the first time period to the second time period. Specifically, clinicians improved in flowsheet documentation (30.4% to 57.1%), approved smart phrase use (39.3% to 50.9%.), and clinically relevant documentation (32.1% to 56.6%). Analysis of patient outcomes regarding the four outcome measures during the second time period is in progress.

Conclusions

Clinicians increased their adherence to documentation standards, but further improvement is needed. Patient outcome results will provide useful information regarding effectiveness of the physical therapy standard of care for patients with TKA and guide any needed modification to the standard.

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Clinician Adherence to Documentation Standards and Functional Outcomes for Patients with Total Knee Arthroplasty

Background

Total knee arthroplasty (TKA) is a common procedure performed on over 600,000 patients with chronic osteoarthritis each year. The rehabilitation for TKA involves extensive physical therapy for adequate recovery (Losina et al., 2016). A standard of care regarding outcome measures for this patient population was not established at The University of Vermont Medical Center. The outpatient physical therapists developed a standard set of outcome measures for patients with TKA that assessed patient progress.

Objective

The objective of this quality improvement project was to evaluate: 1) clinician adherence to documentation standards and 2) patient functional outcomes by using four outcome measures (30 Second Chair Stand, Gait Speed, Timed Up and Go, and Single Limb Stance Test).

Methods

Audits were completed for 32 patients with TKA who received physical therapy services from October 2017 through March 2018 and from June 2018 through September 2018. The data were extracted manually and recorded in an Excel spreadsheet. Clinician adherence to documentation standards was examined by counting the instances of outcome measure scores entered in the flowsheet, approved smart phrases used, and clinically relevant documentation. Patient outcomes included the achievement of established goals as reflected by the outcome measures.

Results

The preliminary results showed that clinicians increased their adherence to clinical documentation standards from the first time period to the second time period. Specifically, clinicians improved in flowsheet documentation (30.4% to 57.1%), approved smart phrase use (39.3% to 50.9%.), and clinically relevant documentation (32.1% to 56.6%). Analysis of patient outcomes regarding the four outcome measures during the second time period is in progress.

Conclusions

Clinicians increased their adherence to documentation standards, but further improvement is needed. Patient outcome results will provide useful information regarding effectiveness of the physical therapy standard of care for patients with TKA and guide any needed modification to the standard.