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.
From the Department of Orthopaedic Surgery, SUMMA Health System, Akron, OH (Dr. Urchek), the Department of Pediatric Orthopaedic Surgery, Akron Children's Hospital, Akron, OH (Ms. Morscher and Dr. Adamczyk) and the Department of Statistics, University of Akron, Akron, OH (Dr. Steiner).
Correspondence to Dr. Adamczyk: email@example.com
Dr. Adamczyk or an immediate family member is a member of a speakers' bureau or has made paid presentations on behalf of OrthoPediatrics. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Urchek, Ms. Morscher, and Dr. Steiner.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.