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 practice residency clinic serving a primarily low-socioeconomic urban population. Patients: Children younger than 6 years receiving well-child care visits. Intervention: Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment 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 well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form. Results: A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form. Conclusions: The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.