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Influence of Structured Encounter Forms on Documentation by Community Pediatricians

Background. Age‐specific structured encounter forms for well‐child examinations have been shown to improve thoroughness of documentation among pediatric house staff. This study evaluated the influence of such forms on completeness of documentation by practicing pediatricians. Methods. In this before‐after trial at 5 urban community health clinics, participants were 8 pediatricians practicing for at least 1 year. Brief group training sessions on use of the forms were provided to the participating physicians. Completeness of documentation was defined as the proportion of elements from a full well‐child examination recorded in the medical record. Results. After introduction of the standardized forms, completeness of documentation significantly increased for all components. Conclusions. The use of age‐specific structured encounter forms improved the completeness of documentation of pediatric well‐child examinations done by pediatricians.