USE OF A STRUCTURED ENCOUNTER FORM TO IMPROVE WELL-CHILD CARE DOCUMENTATION

Objective: To determine if a structured encounter form for well-child care improves documentation of well-child care. Design: Retrospective medical record review of a before-and-after trial. Setting: Family pra ctice residency clinic serving a primarily low-socioeconomic urban pop ulation. Patients: Children younger than 6 years receiving well-child care visits. Intervention: Detailed checklists were developed and impl emented in 1994 for each of 12 well-child examinations for the assessm ent of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force. Main Outcome Measures: Documentation of multiple aspects of we ll-child care, including developmental assessment, safety and nutritio n counseling, and laboratory tests for B-month periods in 1993 and 199 4, before and after implementation of the structured encounter form. R esults: A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of th e 23 aspects of well-child care that were studied. Screening test rate s were less than optimal despite the encounter form. Conclusions: The structured encounter form was very effective in improving documentatio n of almost all aspects of well-child care. However, effective communi cation is needed among physicians, nurses, and parents to ensure optim al screening test rates.