Data discipline in electronic medical records: Improving smoking status documentation with a standardized intake tool and process.

OBJECTIVE To evaluate the transformation in smoking status documentation after implementing a standardized intake tool as part of a primary care smoking cessation program. DESIGN A before-and-after evaluation of smoking status documentation was conducted following implementation of a smoking assessment tool. To evaluate the effect of the intervention, the Canadian Primary Care Sentinel Surveillance Network was used to extract aggregate smoking data on the study cohort. SETTING Academic primary care clinic in Kingston, Ont. PARTICIPANTS A total of 7312 primary care patients. INTERVENTIONS As the first phase in a primary care smoking cessation program, a standardized intake tool was developed as part of a vital signs screening process. MAIN OUTCOME MEASURES Documented smoking status of patients before implementation of the intake tool and documented smoking status of patients in the 6 months after its implementation. RESULTS Following the implementation of the standardized intake tool, there was a 55% (P < .001; 95% CI 0.53 to 0.56) increase in the proportion of patients with a completed smoking status; more than 1100 former smokers were identified and the documented smoking rate in this cohort increased from 4.4% to 16.2%. CONCLUSION This study shows that the implementation of an intake tool, integrated into existing clinical operational structures, is an effective way to standardize clinical documentation and promotes the optimization of electronic medical records.