Enhancing the Timeliness of EMR Documentation in Resident Doctors: The Role of PDCA Cycle Management

Abstract

Background The role of the Plan-Do-Check-Act (PDCA) cycle in managing the timeliness of electronic medical records (EMRs) remains unclear. Therefore, this study aimed to evaluate the effect of PDCA management in improving the timeliness of EMR for resident doctors. Method This study had a before and after design. The 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, which was managed by the current department practice. The resident doctors from September 2022 to June 2023 were included in the PDCA group, which was managed by the PDCA cycle. The incidences of late EMRs and unqualified EMRs were compared between the two groups and the influencing factors of the occurrence of late EMRs and unqualified EMRs were explored. Results A total of 314 resident doctors were included, with 162 doctors in the PDCA group and 152 doctors in the control group. The incidences of late EMRs (5.40% vs. 2.56%, P = 0.005) and unqualified EMRs (1.05% vs. 0.00%, P < 0.001) in the PDCA group were significantly lower than those in the control group. The timeliness of the first disease course records (0.24% vs. 0.00%, P = 0.023) and the first-ward-round records (0.36% vs. 0.00%, P = 0.035) were also improved significantly. After incorporating confounding factors, including age, sex, academic degree, working hours, and major, PDCA management still significantly reduced the occurrence of unqualified EMRs (P < 0.001) with an adjusted OR of 0.166 (95% CI 0.067–0.416) and a probability of 83.4% (0.166–1 = − 0.834). Conclusion This study successfully developed PDCA management and revealed that it is beneficial to enhance the timeliness of EMR while concurrently reducing the incidence of unqualified or delayed entries among resident doctors.