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.