Chen et al.

BMC Medical Education (2024) 24:1367 BMC Medical Education

https://doi.org/10.1186/s12909-024-06134-2

RESEARCH Open Access

Enhancing the timeliness of EMR

documentation in resident doctors: the role
of PDCA cycle management
Jiaoting Chen1,2, Zihan Li1, Wananqi Ma1, Yu Tang1, Can Liu1, Shanshan Ma1, Ming Xu1 and Qiongwen Zhang1,2*

Abstract
Background The impact of the Plan-Do-Check-Act (PDCA) cycle in improving the timeliness of electronic medical
record documentation (EMRd) remains uncertain. EMRd that is completed beyond the specified time is classified
as late EMRd, while unqualified EMRd refers to electronic medical records with important sections that are not
completed on time according to the Chinese Basic Norms of Medical Records Writing. This study aimed to evaluate
the effectiveness of PDCA management in improving the timeliness of EMRd among resident doctors.
Method This study utilized a before and after design. Resident doctors rotating in the Head and Neck Oncology
Department of West China Hospital, Sichuan University, from November 2021 to August 2022 were classified as the
control group and did not receive specific training on the timeliness of EMRd. Those rotating from September 2022 to
June 2023 were assigned to the PDCA group, which was managed using the PDCA cycle. The effectiveness of PDCA
cycle management was evaluated by comparing the incidence of late EMRd and unqualified EMRd between two
groups. Univariate and multivariate binary logistic regression analyses were conducted tocontrol for confounding
factors.
Results A total of 245 resident doctors were included, with 162 doctors in the PDCA group and 152 doctors in
the control group. The incidences of late EMRd (5.40% vs. 2.56%, P = 0.005) and unqualified EMRd (1.05% vs. 0.00%,
P < 0.001) were significantly lower in the PDCA group than those in the control group. After adjusting confounding
factors, PDCA management still significantly reduced the occurrence of unqualified EMRd (P < 0.001) with an
adjusted odds ratio (OR) of 0.166 (95% CI 0.067–0.416) and late EMRd (P < 0.001) with an adjusted OR of 0.318 (95% CI
0.181–0.557).
Conclusion This study successfully developed PDCA management and demonstrated its effectiveness in improving
the timeliness of EMRd while concurrently reducing the incidence of unqualified and late entries among resident
doctors.
Keywords Electronic medical records, Plan-do-check-act cycle, Timeliness, Resident doctors

*Correspondence:
Qiongwen Zhang
[email protected]
1
West China School of Medicine, Sichuan University, Chengdu
610041, China
2
Department of Head and Neck Oncology, Cancer Center, West China
Hospital, Sichuan University, Chengdu 610041, China

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the
licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or
exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit ​h​t​​​​t​p​:​/​/​c​r​e​​a​​​t​i​
v​e​​c​​o​​m​​m​​o​n​s​.​o​r​g​/​l​i​c​e​n​s​e​s​/​b​y​-​n​c​-​n​d​/​4​.​0​/​​​​.​ ​​​

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 2 of 10

Introduction In this study, resident doctors refer to those undergoing

Electronic medical records have become an integral part clinical training in our hospital. The duration of rotation
of modern medical practice, serving as essential tools in our department varied depending on the majors, rang-
for doctors [1]. Electronic medical records form a rich ing from 2 months to 12 months. Therefore, the impact
repository of information, that supports the development of this rotation time was considered as part of the influ-
of better clinical prognostic tools [2], surgical schedul- ence of majors on the timeliness of EMRd. Moreover,
ing tools [3], decision support systems [4], public health there were some overlapping resident doctors between
surveillance [1, 5]. However, in the context of the Chi- the two groups, and the specific number of these overlap-
nese clinical training system, limited working hours and ping doctors was recorded.
a growing patient population heighten the importance
of timely EMRd [6–8]. The timeliness of EMRd refers to Study variables
the ability of doctors to complete medical records within (1) Basic information of resident doctors was recorded,
the prescribed time. EMRd completed beyond the speci- including age, sex, postgraduate year (PGY), major, and
fied time is considered late EMRd. Several important weekly working hours. Doctors with missing information
parts of EMRd are more likely to cause medical risks, were not eligible for inclusion.
including the first disease course records, shift records, (2) Timeliness issues often occur in several parts of
stage summaries, the first ward-round records, and sur- electronic medical records, including homepages, disease
gical records. According to the Chinese Basic Norms of course records, shift records, stage summaries, ward-
Medical Records Writing, the EMRd containing these round records, and surgical records.
parts that were not completed on time is classified as The homepage contained the basic patient informa-
an unqualified EMRd. Few articles have been published tion, diagnosis and treatment, hospitalization process,
on approaches to improving the timeliness of EMRd, and expenses. Disease course records encompassed the
including enhancing the application of electronic medical first disease course records, daily disease course records,
records [9], conducting assessments and public displays superior physician ward-round records, shift handover
[10], and designing new structured data-entry forms [6]. (succession) records, surgical records, and stage sum-
Given the current unsatisfactory rate of timely EMRd, maries. The first disease course records were the first
additional new improvement measures are necessary. documents written after admission, detailing the case
The Plan-Do-Check-Act (PDCA) cycle, also known as characteristics, diagnostic basis, differential diagno-
the “quality loop,” is a management model for continuous ses, and treatment plan. Daily disease course records
improvement [11] and has demonstrated its effectiveness were continuous records during hospitalization, cover-
in various medical scenarios, including hyperglycemia ing patient status, specialized examinations, diagnosis,
management [12], nutrition management [13], and infec- treatments, and their efficacy, as well as the opinions
tion rate control in operating rooms [14]. Furthermore, from superior physicians when ward rounds. The supe-
the PDCA cycle has been applied in modern hospital rior physician ward-round records captured the superior
quality management and demonstrated its efficiency [15– physician’s analysis of the patient’s condition, diagnosis,
17]. Considering the wide application of electronic medi- differential diagnosis, current treatments and efficacy,
cal records and the lack of effective management models and plans for further diagnosis and treatment. The first
to reduce late EMRd, this study aimed to explore whether ward-round records were the first superior physician
the implementation of PDCA management among resi- ward-round records written after admission. The shift
dents can improve the timeliness of EMRd compared to handover (succession) records summarized the patient’s
traditional management approaches. condition, diagnosis, and treatment, by the hando-
ver (succession) physician when changing the patient’s
Materials and methods attending physician. The surgical record was a specialized
Study population document that reflected the overall surgical situation,
This study employed a before and after design. Resi- surgical process, intraoperative findings and measures.
dent doctors rotating in the Head and Neck Oncology For patients with prolonged hospital stays, stage sum-
Department of West China Hospital, Sichuan University maries offered monthly overviews of patients’ conditions,
were recruited for the study. Those who rotated between diagnoses, and treatments.
November 2021 and August 2022 were classified as the (3) The late EMRd were defined as those that were not
control group and did not receive training on the time- written promptly. The timeliness issues of EMRd were
liness of EMRd. Resident doctors rotating from Sep- categorized as follows: (a) for patients with stable condi-
tember 2022 to June 2023 were included in the PDCA tions, the completion time of daily disease course records
group, which implemented the PDCA cycle for quality exceeded 3 days; (b) the first disease course records
management. were not completed within 8 h after admission; (c) shift

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 3 of 10

records were not finished before the succession records Intervention

were written; (d) the completion time of stage summaries Based on previous research on the successful application
exceeded 30 days during the hospitalization; (e) the first of PDCA cycle management and the work experience of
ward-round records by the superior physicians were not medical team leaders and EMRd quality controllers [13,
completed within 48 h of admission; (f ) surgical records 18], the following PDCA cycle management measures
were not completed within 24 h after surgery; (g) impor- were developed to improve the timeliness of medical
tant examination results were not documented in the records. PDCA cycle management was implemented in
disease course records; (h) EMR homepages were not the PDCA group, and the specific steps were as follows
completed within 24 h after discharge; EMRd with one (Fig. 1):
or more of severe timeliness problems [(b) to (f )] were
classified as unqualified EMRd according to the Chinese Plan
Basic Norms of Medical Records Writing. All these time-
liness issues can be identified by the medical records sys- •  Formulate the training plan: develop the training
tem of our hospital. content and schedule according to the Chinese Basic
Norms of Medical Records Writing. Strengthening
the standard training of EMRd for resident doctors
and emphasizing the specified time for completing

Fig. 1 The specific implementation diagram of the PDCA for enhancing the timeliness of electronic medical records

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 4 of 10

each part of medical records, can enhance the team in the communication group, supervising
timeliness of EMR writing [19]. them to enhance learning and rectification. This
•  Establish an EMRd review team: the review team communication method was expected to contribute
consisted of an EMRd quality controller and to mutual supervision and promotion among
medical team leaders. This team was responsible for medical teams [26].
supervising the EMRd of their respective medical
teams and providing reminders before the specified
time. Improving the internal review mechanism and Check
strengthening cooperation among medical team
leaders and resident physicians can effectively help •  The timeliness rates of EMRd were assessed by the
formulate and implement improvement measures three-tier supervision every month in two groups.
[20, 21]. However, the control group did not receive The process was carried out by the medical team
any review or reminders before the specified time leaders, the EMRd quality controller, and the special
without the EMRd review team. department of the hospital based on the evaluation
•  Determine the key verification contents: based on of the medical records system.
the previous timeliness issues of late EMRd, we •  The evaluation of the PDCA management
summarized the key verification contents, focusing effectiveness involved the implementation of the
on the timeliness of the homepage, the first disease plan during the Do phase and the occurrence of late
course records, daily disease course records, shift EMRd and unqualified EMRd.
records, stage summaries, the first ward-round •  The timeliness issues in late EMRd were analyzed,
records, and surgical records. guiding adjustments in the focus of training and
•  Determine immediate feedback methods: after review.
finding a late EMRd, the EMRd quality controller
was responsible for reminding the medical teams
promptly to promote learning and rectifications, so Act
that resident doctors make continuous progress [22,
23]. •  A doctor who excelled in timely EMRd was
selected for a 5% performance reward and publicly
acknowledged in the department. Hold talks with
Do doctors with unqualified EMRd and strengthen their
training and supervision.
•  Conduct regular training: the training aimed to •  Discussions on unqualified EMRd were organized to
introduce the content and criteria of the review help doctors learn from mistakes.
to the doctors, and enable them to master the •  Finally, the EMRd review team adjusted the focus of
requirements of EMRd timeliness to reduce the training and review based on the timeliness issues
number of late EMRd [24]. in late EMRd and revised the management plan
•  Training methods: the training started with to address the problems encountered during the
online training (remote meetings, online lectures, implementation and management.
and online Q&As) and offline training (morning
meetings and sessions) [25]. The training was
arranged twice a week. Evaluation indicators
•  Establish communication groups via social media: The department’s timeliness of EMRd was evaluated by
first, each medical team leader reviewed the the proportion of electronic medical records with dif-
timeliness of EMRd, promptly communicated the ferent timeliness issues each month. The effectiveness of
review outcomes, and reminded the resident doctors PDCA management was examined by comparing these
to complete the unfinished EMRd through a WeChat proportions between the two groups.
platform communication group. The EMRd quality
controller conducted a second review and provided Statistical analysis
the final reminders before the specified time. Late Normality tests were conducted for continuous vari-
EMRd should be reported and modified promptly ables. Normally distributed continuous variables were
even though they were still recorded by the system. presented as mean ± standard deviation, and non-nor-
If any late EMR, especially unqualified EMR, was mally distributed continuous variables were reported as
found, the EMRd quality controller should provide the median and range [25th-75th percentile]. Categori-
immediate feedback to the corresponding medical cal variables were expressed as counts and percentages.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 5 of 10

Independent t-test and Mann-Whitney U test were group adopted the PDCA management for the timeliness
used for continuous variables as appropriate. The chi- of EMRd. Notably, there were 69 resident doctors who
square test and Fisher’s exact test were applied for cat- were present in both groups. The basic characteristics of
egorical variables. Univariate and multivariate binary all participating doctors were presented in Table 1. The
logistic regression analyses were performed to identify majority of the participants were under 30 years old (n =
independent factors affecting the timeliness of EMRd, 152, 62.0%) held a bachelor’s degree (n = 149, 60.8%), and
with results presented as odds ratios (ORs). The results worked 40 to 60 hours per week (n = 203, 82.9%). There
were considered statistically significant at P < 0.05 and all were no significant differences in most of the basic infor-
tests were 2-tailed. Data analysis was conducted using mation between the two groups, while the doctors in the
the Statistical Package for the Social Sciences (SPSS) soft- PDCA group had a significantly shorter PGY compared
ware (version 26.0, SPSS Inc., Chicago, IL, USA). to those in the control group (P < 0.001).

Results The effectiveness of PDCA management

Between November 2021 and June 2023, we included 245 There was no significant difference in the total number
resident doctors, and no one was excluded due to incom- of electronic medical records between the two groups. As
plete information. The control group included 152 doc- indicated in Table 2, the implementation of PDCA cycle
tors who underwent rotation from November 2021 to management model significantly decreased the percent-
August 2022, while 162 doctors from September 2022 to age of late EMRd (5.40% vs. 2.56%, P = 0.005) and unqual-
June 2023 were assigned to the PDCA group. The PDCA ified EMRd (1.05% vs. 0.00%, P < 0.001). Moreover, the
percentage of EMRd with first disease course records not
Table 1 Baseline characteristics of two groups before completed within 8 h of patient admission in the PDCA
management group was significantly lower than that in the control
Item Control PDCA Overall p- group (0.24% vs. 0.00%, P = 0.023). In addition, the timeli-
group group (n = 245) Value
(n = 152) (n = 162)
ness of the 3-day disease course records (2.93% vs. 0.61%,
Sex — no. (%) 0.779
P = 0.001) and the first ward-round records (0.36% vs.
Male 41 (27.0) 46 (28.4) 67 (27.3)
0.00%, P = 0.035) also improved significantly due to the
Female 111 (73.0) 116 (71.6) 178 (72.7) implementation of the PDCA cycle. Overall, the numbers
Age — yr 0.315 and percentages of EMRd with different timeliness issues
<30 103 (67.8) 101 (62.3) 152 (62.0) were reduced after employing PDCA management.
≥ 30 49 (32.2) 61 (37.7) 93 (38.0)
Academic degree — 0.246 Factors influencing unqualified medical records
no. (%) To further investigate the effectiveness of the PDCA
bachelor's degree 100 (65.8) 97 (59.9) 149 (60.8) cycle management model, we identified factors influenc-
Master's degree 31 (20.4) 31 (19.1) 54 (22.0) ing the occurrence of unqualified EMRd and controlled
doctor's degree 21 (13.8) 34 (21.0) 42 (17.2) for potential confounders using univariate and multivari-
Major — no. (%) 0.205 ate binary logistic regression analyses. Six potential con-
hematological 5 (3.3) 5 (3.1) 8 (3.3) founding factors were examined: age, sex, PGY, academic
malignancy degree, working hours, and major, of which only age sig-
Thoracic tumors 29 (19.1) 32 (19.8) 44 (18.0) nificantly affected the occurrence of unqualified EMRd
Abdominal tumors 32 (21.1) 38 (23.5) 52 (21.2) (P = 0.010). Compared with doctors older than 30 years
Internal medicine and 52 (34.2) 37 (22.8) 76 (31.0)
old, those younger than 30 years old have a higher occur-
others
rence of unqualified EMRd, with an OR of 3.622 (95% CI
Head and neck tumors 34 (22.4) 50 (30.9) 65 (26.5)
1.363–9.621). Details of all ORs for the influencing fac-
Working hours — no. 0.002
(%) tors were presented in Table 3. Incorporating age and
< 40 h per week 3 (2.0) 14 (8.6) 14 (5.7) PDCA management into a multivariate regression analy-
40–60 h per week 139 (91.4) 125 (77.2) 203 (82.9) sis, the results showed that PDCA cycle management can
> 60 h per week 10 (6.6) 23 (14.2) 28 (11.4) still significantly reduce the occurrence of unqualified
PGY — no. (%) < 0.001 EMRd (P < 0.001) with an adjusted OR of 0.166 (95% CI
1 25 (16.4) 56 (34.6) 72 (29.4) 0.067–0.416) (Table 4).
2 45 (29.6) 56 (34.6) 70 (28.6)
3 41 (27.0) 28 (17.3) 51 (20.8) Factors influencing late medical records
4* 41 (27.0) 22 (13.6) 52 (21.2) Univariate regression analysis identified age (P = 0.028),
PGY: post graduate year sex (P = 0.044), PGY, and major as potential confounding
*: more than 3 years factors (Table 3), which were subsequently included in

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 6 of 10

Table 2 Comparison of the medical records with different timeliness issues between two groups
Items Control group PDCA group Overall p-Value
The total number of medical records 391 ± 61.53 344.50 ± 80.03 367 ± 73.51 0.160
The number of late medical records 24.00 9.00 (6.00-10.50) 11.00 < 0.001
(13.00-34.75) (9.00–25.00)
The percentage of late medical records 5.40% 2.56% 3.35% 0.005
(2.99%-8.47%) (1.42%-3.58%) (2.44%-5.46%)
The number of unqualified medical records 4.50 (2.75–6.25) 0.00 (0.00–1.00) 1.50 (0.00-4.75) < 0.001
The percentage of unqualified medical records 1.05% 0.00% 0.49% < 0.001
(0.69%-1.49%) (0.00%-0.32%) (0.00%-1.14%)
The percentage of medical records with disease course records completion time 2.93% 0.61% 1.31% 0.001
exceeding 3 days for patients in stable conditions (1.34%-5.76%) (0.43%-1.25%) (0.60%-2.97%)
The percentage of medical records with the first disease records completion time 0.24% 0.00% 0.00% 0.023
exceeding 8 hours after admission (0.00%-0.43%) (0.00%-0.00%) (0.00%-0.29%)
The percentage of medical records with shift records that were not completed 0.21% 0.00% 0.00% 0.063
timely (0.00%-0.55%) (0.00%-0.06%) (0.00%-0.28%)
The percentage of medical records with stage summaries completion time exceed- 0.00% 0.00% 0.00% 0.481
ing 30 days (0.00%-0.05%) (0.00%-0.00%) (0.00%-0.00%)
The percentage of first ward-round records by the superior physicians with the 0.36% 0.00% 0.00% 0.035
completion time exceeding 48 hours after admission (0.00%-0.54%) (0.00%-0.08%) (0.00%-0.41%)
The percentage of medical records with surgical records completion time exceeding 0.00% 0.00% 0.00% 0.481
24 hours after surgery (0.00%-0.05%) (0.00%-0.00%) (0.00%-0.00%)
The percentage of medical records that didn't record the important results of 0.00% 0.00% 0.00% 0.912
examinations (0.00%-0.35%) (0.00%-0.25%) (0.00%-0.27%)
The percentage of medical records with the homepage completion time exceeding 1.05% ± 0.42% 1.56% ± 0.893% 1.31%±0.73% 0.117
24 hours after discharge
PDCA: Plan-Do-Check-Act
Data are Mean ± SD or median (IQR).

the multivariate regression analysis. The results showed unintended challenges, including increased work hours,
that the PDCA cycle management could still effectively time constraints, and potential miscommunication
reduced the occurrence of late EMRd (P < 0.001), with between patients and healthcare providers [30]. There-
an adjusted OR of 0.318 (95% CI 0.181–0.557). Age may fore, the application of scientific management tools and
be a potential predictor for the occurrence of late EMRd the provision of EMRd training are indispensable com-
(P = 0.055), while sex did not have a statistically signifi- ponents in the training of resident doctors, ensuring they
cant effect on the occurrence of late EMRd (P = 0.155). are equipped to navigate these complexities effectively
Compared to doctors who had graduated for 4 years and maintain the highest standards of patient care.
or more, those who graduated 2 years ago had a higher In response to these challenges, our study explored
incidence of late EMRd (P = 0.008), with an OR of 1.027 the Plan-Do-Check-Act (PDCA) cycle as a strategic
(95% CI 1.301–5.994). Furthermore, the incidence of late intervention to enhance the timeliness of EMRd among
EMRd was significantly lower among doctors in internal resident doctors. The PDCA cycle, a structured qual-
medicine and other majors compared to those in head ity management model, involved establishing a medical
and neck tumors (P = 0.021), with an OR of 0.414 (95% CI records review team and formulating a comprehensive
0.196–0.873) (Table 4). training plan in the Plan phase [31]. During the Do phase,
training was delivered according to predefined education
Discussion standards. In the subsequent Check phase, we identi-
The ability of resident doctors to efficiently share patient fied challenges, analyzed underlying timeliness issues,
information through electronic medical records has and incorporated improvement measures into subse-
become a critical focus for medical educators and poli- quent PDCA cycles, fostering a continuous enhance-
cymakers. This focus is justified by the crucial role that ment environment. Notably, practical measures such as
timely EMRd plays in effective patient care and coordi- network meetings and real-time communication were
nation among healthcare professionals [6]. Timely EMRd employed for immediate response to late EMRd. Our
are essential not just for emergency scenarios, where they findings demonstrated a significant increase in the pro-
can be life-saving, but also for reducing the risk of medi- portion of timely EMRd following the PDCA implemen-
cal errors across all areas of healthcare delivery [27–29]. tation, underscoring its effectiveness in improving EMRd
However, the implementation of EMRd has introduced management practices among residents, which has been

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 7 of 10

Table 3 Univariate logistic analysis of influencing factors for the occurrence of unqualified and late medical records
Variable unqualified medical records late medical records
Units β Odds Ratio 95%CI p-Value β Odds Ratio 95%CI p-Value
Age
< 30 1.287 3.621 1.363; 9.621 0.010 0.596 1.815 1.067; 3.086 0.028
≥ 30 Ref Ref
Sex
Male 0.350 1.419 0.673; 2.994 0.358 0.535 1.707 1.015; 2.872 0.044
Female Ref Ref
PDCA cycle
Yes -1.813 0.163 0.066; 0.405 < 0.001 -0.825 0.438 0.268; 0.717 0.001
No Ref Ref
PGY
1 -0.878 0.416 0.116; 1.488 0.177 -0.038 0.963 0.451; 2.058 0.923
2 0.253 1.287 0.489; 3.387 0.609 0.738 2.091 1.047; 4.176 0.037
3 0.304 1.356 0.483; 3.809 0.563 0.036 1.037 0.475; 2.265 0.928
4* Ref Ref
Academic degree
bachelor's degree -0.148 0.862 0.348; 2.138 0.749 -0.469 0.626 0.337; 1.164 0.139
Master's degree -0.308 0.735 0.231; 2.336 0.601 -0.651 0.522 0.238; 1.143 0.104
doctor's degree Ref Ref
Working hours
< 40h per week -0.032 0.969 0.082; 11.512 0.980 -0.619 0.538 0.143; 2.028 0.360
40-60h per week 0.760 2.138 0.488; 9.363 0.313 -0.273 0.761 0.357; 1.621 0.479
> 60h per week Ref Ref
Major
Hematological malignancy 0.615 1.850 0.343; 9.969 0.474 1.046 2.845 0.743; 10.894 0.127
Thoracic tumors 0.372 1.451 0.563; 3.738 0.441 -0.231 0.794 0.390; 1.616 0.524
Abdominal tumors -0.046 0.955 0.355; 2.567 0.927 0.052 1.054 0.542; 2.047 0.877
Internal medicine and others -0.820 0.440 0.144; 1.347 0.151 -0.732 0.481 0.242; 0.954 0.036
Head and neck tumors Ref Ref
PDCA: Plan-Do-Check-Act
PGY: post graduate year
*: more than 3 years

proven to improve the clinical skills of resident doctors This study has several limitations that warrant discus-
[32]. This suggests that structured, cyclic approaches to sion. The use of a before-and-after design raised concerns
process management can profoundly impact the timeli- about potential systematic bias between the two groups.
ness of EMRd. However, given the prominent timeliness issues of EMRd
Additionally, our analysis identified key factors con- within the same department, it was impractical not to
tributing to late EMRd. We noted correlations between implement measures for some doctors. Moreover, dur-
late EMRd and variables such as age, PGY, and majors. ing the research period, the criteria for determining the
For instance, residents in their second PGY often han- timeliness issues of EMRd did not change. Timeliness
dle higher patient volumes compared to their first year, issues in both groups were evaluated through a three-tier
which can lead to increased workload and time con- supervision process.
straints, potentially impeding timely documentation. In the context of the Chinese clinical training system,
This finding is consistent with previous research indicat- a certain proportion of resident doctors were present
ing that after 12 months of ambulatory experience, resi- in both groups. Despite this overlap, none of these doc-
dent doctors saw more patients per day and spent less tors had previously received training on the timeliness
time reviewing each patient’s electronic health record of EMRd, and the impact of working hours and PGY
[33]. Despite the influence of these variables, the imple- on the timeliness of EMRd was analyzed. We also veri-
mentation of the PDCA cycle was the most significant fied the effectiveness of PDCA cycle management in
factor in reducing late entries, highlighting its potential improving the timeliness of medical records in both
to transform EMRd practices. repeated and non-repeated doctors (Supplementary
Tables 1–5). Therefore, it was believed that the presence

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 8 of 10

Table 4 Multivariate logistic analysis of influencing factors for may indicate an increase in workload as well as work effi-
the occurrence of late and unqualified medical records ciency [33, 34].
Variable Units β Odds 95%CI p- Furthermore, the application of the PDCA cycle in this
Ratio Value
study was restricted to resident doctors, and its effective-
late medical records
ness in enhancing EMRd timeliness among more experi-
Age
enced physicians warrants further exploration. Moreover,
< 30 0.611 1.842 0.987; 0.055
3.439 our study’s findings, derived from a single Chinese hospi-
≥ 30 Ref tal, may not be universally applicable due to variations in
Sex medical records management practices across different
Male 0.421 1.524 0.853; 0.155 healthcare systems. Additionally, this article discussed
2.723 the impact of PDCA cycle management on the timeliness
Female Ref of EMRd, but it did not address whether such manage-
PDCA cycle ment affected the quality of EMRd, including accuracy
Yes -1.147 0.318 0.181; < 0.001 and completeness [35]. To overcome these limitations,
0.557 future research should extend to multi-center studies in
No Ref varied healthcare settings, include larger sample sizes,
PGY and explore both the timeliness and quality of EMRd.
1 0.591 1.805 0.753; 0.185 Such studies could provide a more comprehensive evalu-
4.326
ation of the PDCA cycle’s efficacy in improving EMRd
2 1.027 2.793 1.301; 0.008
5.994
practices across diverse medical environments.
3 0.031 1.032 0.453; 0.940
2.351 Conclusions
4* Ref In conclusion, this study successfully developed and
Major implemented a PDCA cycle tailored for managing the
Hematological 0.888 2.431 0.589; 0.219 timeliness of EMRd among resident doctors. Our find-
malignancy 10.030 ings demonstrated that the application of the PDCA
Thoracic tumors -0.242 0.785 0.364; 0.538 management method significantly enhanced the timeli-
1.694 ness of EMRd while concurrently reducing the incidence
Abdominal 0.049 1.050 0.514; 0.894 of unqualified or late entries. These encouraging results
tumors 2.145
underscore the potential of PDCA cycle management as
Internal medi- -0.882 0.414 0.196; 0.021
cine and others 0.873 a robust framework not only for improving EMRd man-
Head and neck Ref agement but also as a versatile tool in the broader context
tumors of resident training and skill development.
unqualified medical records
Abbreviations
Age PDCA Plan-Do-Check-Act
< 30 1.254 3.503 1.296; 0.013 EMRd Electronic medical record documentation
9.470 PGY postgraduate year
ORs odds ratios
≥ 30 Ref
SPSS The Statistical Package for the Social Sciences
PDCA cycle
Yes -1.794 0.166 0.067; < 0.001
0.416
Supplementary Information
No Ref The online version contains supplementary material available at ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​
PDCA: Plan-Do-Check-Act g​/​1​0​.​1​1​8​6​/​s​1​2​9​0​9​-​0​2​4​-​0​6​1​3​4​-​2​​​​.​ ​​
PGY: post graduate year
*: more than 3 years Supplementary Material 1

Acknowledgements
of duplicate populations between the two groups did not None.
affect the assessment of PDCA effectiveness. Addition-
Author contributions
ally, although the doctors in the PDCA group had a sig- QZ designed this work. JC wrote the manuscript text. JC and ZL revised the
nificantly shorter PGY compared to those in the control manuscript substantively. JC and WM conducted the data analysis. YT, CL,
group, after incorporating PGY as a confounding factor, SM, and MX collected the data. QZ edited and revised the manuscript. Both
authors have read the manuscript and approved the final version.
PDCA management still significantly reduced the occur-
rence of late EMRd and unqualified EMRd. A higher PGY

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 9 of 10

Funding factors influencing their cognition. BMC Med Educ. 2023;23(1):294. ​h​t​t​​p​s​:​/​​/​d​o​​
The author(s) reported there is no funding associated with the work featured i​.​​o​r​g​/​1​0​.​1​1​8​6​/​s​1​2​9​0​9​-​0​2​3​-​0​4​2​9​3​-​2​​​​.​ Epub 2023/05/02.
in this article. 12. Chen J, Cai W, Lin F, Chen X, Chen R, Ruan Z. Application of the Pdca cycle for
managing hyperglycemia in critically ill patients. Diabetes Therapy: Res Treat
Data availability Educ Diabetes Relat Disorders. 2023;14(2):293–301. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​0​7​/​s​
The datasets used and analyzed during the current study are available from 1​3​3​0​0​-​0​2​2​-​0​1​3​3​4​-​9​​​​.​ Epub 2022/11/25.
the corresponding author upon reasonable request. The data are not publicly 13. Zeng X, Huang X, Wang P, Liao J, Wu L, Liu J, et al. The application of the Pdca
available due to privacy or ethical restrictions. cycle in the Nutritional Management of patients with Nasopharyngeal Carci-
noma. Supportive care cancer: Official J Multinational Association Supportive
Care Cancer. 2023;31(5):251. https:/​/doi.or​g/10.10​07/s​00520-023-07724-4.
Declarations Epub 2023/04/11.
14. Chen H, Wang P, Ji Q. Analysis of the application Effect of Pdca Cycle Manage-
Ethics approval and consent to participate ment combined with risk factor management nursing for reducing infection
Written informed consent was obtained from the individual participants or rate in operating room. Front Surg. 2022;9:837014. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​3​3​8​9​/​f​s​
their guardians. The study was approved by the medical ethics committee u​r​g​.​2​0​2​2​.​8​3​7​0​1​4​​​​.​ Epub 2022/04/05.
of West China Hospital, Sichuan University, with the approval number 15. Harolds JA. Quality and Safety in Healthcare, Part Xc: the A3 Approach and
2024 − 1658. All procedures involving human participants performed in lean in Healthcare. Clin Nucl Med. 2023;48(7):e358–60. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​9​
this study were in accordance with the ethical standards of the institutional 7​/​r​l​u​.​0​0​0​0​0​0​0​0​0​0​0​0​3​8​5​1​​​​.​ Epub 2021/08/16.
research committee and the 1964 Helsinki Declaration and its later 16. Li Y, Wang H, Jiao J. The application of strong Matrix Management and Pdca
amendments or comparable ethical standards. Cycle in the management of severe Covid-19 patients. Crit Care (London
England). 2020;24(1):157. https:/​/doi.or​g/10.11​86/s​13054-020-02871-0. Epub
Consent for publication 2020/04/19.
Not applicable. 17. Wei W, Wang S, Wang H, Quan H. The application of 6s and Pdca Manage-
ment Strategies in the nursing of Covid-19 patients. Crit Care (London
Competing interests England). 2020;24(1):443. https:/​/doi.or​g/10.11​86/s​13054-020-03124-w. Epub
The authors declare no competing interests. 2020/07/18.
18. Gu S, Zhang A, Huo G, Yuan W, Li Y, Han J, et al. Application of Pdca Cycle
Received: 20 January 2024 / Accepted: 4 October 2024 Management for Postgraduate Medical Students during the Covid-19 pan-
demic. BMC Med Educ. 2021;21(1):308. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​1​8​6​/​s​1​2​9​0​9​-​0​2​1​-​0​
2​7​4​0​-​6​​​​.​ Epub 2021/05/31.
19. Samadbeik M, Fatehi F, Braunstein M, Barry B, Saremian M, Kalhor F, et al.
Education and Training on Electronic Medical Records (Emrs) for Health
References Care professionals and students: a scoping review. Int J Med Informatics.
1. Abid M, Schneider AB. Clinical Informatics and the Electronic Medical Record. 2020;142:104238. https:/​/doi.or​g/10.10​16/j​.ijmedinf.2020.104238. Epub
Surg Clin North Am. 2023;103(2):247–58. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​1​6​/​j​.​s​u​c​.​2​0​2​2​.​1​ 2020/08/23.
1​.​0​0​5​​​​.​ Epub 2023/03/23. 20. Andolsek KM, Nagler A, Dodd L, Weinerth JL. Internal Reviews Benefit Pro-
2. Escobar GJ, Soltesz L, Schuler A, Niki H, Malenica I, Lee C. Prediction of obstet- grams of the Review Team Members and the program under review. J Gradu-
rical and Fetal Complications Using Automated Electronic Health Record ate Med Educ. 2010;2(4):604–9. https:/​/doi.or​g/10.43​00/j​gme-d-10-00063.1.
Data. Am J Obstet Gynecol. 2021;224(2):137–47. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​1​6​/​j​.​a​j​o​ Epub 2011/12/02.
g​.​2​0​2​0​.​1​0​.​0​3​0​​​​.​ .e7. Epub 2020/10/26. 21. Hsih KW, Iscoe MS, Lupton JR, Mains TE, Nayar SK, Orlando MS, et al. The Stu-
3. Attaallah AF, Elzamzamy OM, Phelps AL, Ranganthan P, Vallejo MC. Increasing dent Curriculum Review Team: how we catalyze curricular changes through a
operating room efficiency through Electronic Medical Record Analysis. J Peri- student-centered Approach. Med Teach. 2015;37(11):1008–12. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​
oper Pract. 2016;26(5):106–13. https:/​/doi.or​g/10.11​77/1​75045891602600503. /​1​0​.​3​1​0​9​/​0​1​4​2​1​5​9​x​.​2​0​1​4​.​9​9​0​8​7​7​​​​.​ Epub 2014/12/24.
Epub 2016/07/13. 22. Jug R, Jiang XS, Bean SM. Giving and receiving effective feedback: a review
4. Park YT, Kim YS, Yi BK, Kim SM. Clinical decision support functions and digita- article and how-to Guide. Arch Pathol Lab Med. 2019;143(2):244–50. ​h​t​t​​p​s​:​/​​/​d​
lization of clinical documents of Electronic Medical Record systems. Healthc o​​i​.​​o​r​g​/​1​0​.​5​8​5​8​/​a​r​p​a​.​2​0​1​8​-​0​0​5​8​-​R​A​​​​.​ Epub 2018/08/14.
Inf Res. 2019;25(2):115–23. https:/​/doi.or​g/10.42​58/h​ir.2019.25.2.115. Epub 23. Lee GB, Chiu AM. Assessment and Feedback methods in competency-based
2019/05/28. Medical Education. Annals of allergy, Asthma & immunology: official. Publica-
5. Klompas M, Haney G, Church D, Lazarus R, Hou X, Platt R. Automated identifi- tion Am Coll Allergy Asthma Immunol. 2022;128(3):256–62. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​
cation of Acute Hepatitis B using Electronic Medical Record Data to Facilitate .​1​0​1​6​/​j​.​a​n​a​i​.​2​0​2​1​.​1​2​.​0​1​0​​​​.​ Epub 2021/12/21.
Public Health Surveillance. PLoS ONE. 2008;3(7):e2626. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​3​7​ 24. Robinson KE, Kersey JA. Novel Electronic Health Record (ehr) education inter-
1​/​j​o​u​r​n​a​l​.​p​o​n​e​.​0​0​0​2​6​2​6​​​​.​ Epub 2008/07/10. vention in Large Healthcare Organization improves Quality, Efficiency, Time,
6. Carlson KL, McFadden SE, Barkin S, Improving Documentation Timeliness. and impact on Burnout. Medicine. 2018;97(38):e12319. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​9​
A brighter future for the Electronic Medical Record in Resident Clinics. Acad 7​/​m​d​.​0​0​0​0​0​0​0​0​0​0​0​1​2​3​1​9​​​​.​ Epub 2018/09/22.
Medicine: J Association Am Med Colleges. 2015;90(12):1641–5. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​ 25. Chénard-Roy J, Guitton MJ, Thuot F. Online residency training during the
g​/​1​0​.​1​0​9​7​/​a​c​m​.​0​0​0​0​0​0​0​0​0​0​0​0​0​7​9​2​​​​.​ Epub 2015/06/25. Covid-19 pandemic: a National Survey of Otolaryngology Head and Neck
7. Sun AJ, Wang L, Go M, Eggers Z, Deng R, Maggio P, et al. Night-time com- surgery program directors. J Otolaryngol - head neck Surg = Le J d’oto-rhino-
munication at Stanford University Hospital: perceptions, reality and solutions. laryngologie et de chirurgie Cervicofac. 2021;50(1):65. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​1​8​6​
BMJ Qual Saf. 2018;27(2):156–62. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​1​3​6​/​b​m​j​q​s​-​2​0​1​7​-​0​0​6​7​2​7​​​​​ /​s​4​0​4​6​3​-​0​2​1​-​0​0​5​4​6​-​6​​​​.​ Epub 2021/11/18.
. Epub 2017/10/23. 26. Su JJ, Yu DS. Effects of a Nurse-Led Ehealth Cardiac Rehabilitation Programme
8. Macgregor JM, Sticca R. General surgery residents’ views on work hours on Health outcomes of patients with Coronary Heart Disease: a Randomised
regulations. J Surg Educ. 2010;67(6):376–80. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​1​6​/​j​.​j​s​u​r​g​.​2​0​ Controlled Trial. Int J Nurs Stud. 2021;122:104040. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​1​6​/​j​.​i​j​n​
1​0​.​0​7​.​0​0​8​​​​.​ Epub 2010/12/16. u​r​s​t​u​.​2​0​2​1​.​1​0​4​0​4​0​​​​.​ Epub 2021/08/02.
9. Bennett KJ, Steen C. Electronic Medical Record Customization and the Impact 27. Cuddy MM, Foster LM, Wallach PM, Hammoud MM, Swanson DB. Medical
Upon Chart Completion Rates. Family medicine (2010) 42(5):338 – 42. Epub Student experiences with Electronic Health Records Nationally: a longitudinal
2010/05/13. analysis including School-Level effects. Acad Medicine: J Association Am Med
10. Barbour JR, Brothers TE, Wetherholt SF. Stimulation of interest in Resident Colleges. 2022;97(2):262–70. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​9​7​/​a​c​m​.​0​0​0​0​0​0​0​0​0​0​0​0​4​2​9​0​​​​​
completion of necessary administrative work: implementation and evalua- . Epub 2021/08/05.
tion of a publicly displayed administrative Grade. J Surg Educ. 2010;67(1):48– 28. Walker EJ, MacDonald NE, Islam N, Le Saux N, Top KA, Fell DB. Completeness
51. https:/​/doi.or​g/10.10​16/j​.jsurg.2009.10.006. Epub 2010/04/28. and timeliness of Diphtheria-Tetanus-Pertussis, Measles-Mumps-Rubella,
11. Zhong X, Wu X, Xie X, Zhou Q, Xu R, Wang J, et al. A descriptive study on and Polio vaccines in Young Children with Chronic Health conditions: a
Clinical Department managers’ cognition of the Plan-Do-Check-act cycle and

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Chen et al. BMC Medical Education (2024) 24:1367 Page 10 of 10

systematic review. Vaccine. 2019;37(13):1725–35. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​1​6​/​j​.​v​a​ 33. Holmgren AJ, Lindeman B, Ford EW. Resident Physician Experience and Dura-
c​c​i​n​e​.​2​0​1​9​.​0​2​.​0​3​1​​​​.​ Epub 2019/03/01. tion of Electronic Health Record Use. Appl Clin Inf. 2021;12(4):721–8. ​h​t​t​​p​s​:​/​​/​d​
29. Minard JP, Turcotte SE, Lougheed MD. Asthma Electronic Medical Records o​​i​.​​o​r​g​/​1​0​.​1​0​5​5​/​s​-​0​0​4​1​-​1​7​3​2​4​0​3​​​​.​ Epub 2021/08/05.
in Primary Care: an integrative review. J Asthma: Official J Association Care 34. Turner-Lawrence D, Todd BR. Monthly progression of Emergency Medicine
Asthma. 2010;47(8):895–912. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​3​1​0​9​/​0​2​7​7​0​9​0​3​.​2​0​1​0​.​4​9​1​1​4​1​ Resident Efficiency: what can we expect of our residents throughout train-
1​​​​​. Epub 2010/09/22. ing? J Emerg Med. 2019;57(1):77–81. ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​o​r​g​/​1​0​.​1​0​1​6​/​j​.​j​e​m​e​r​m​e​d​.​2​0​1​
30. Moy AJ, Schwartz JM, Chen R, Sadri S, Lucas E, Cato KD, et al. Measurement 9​.​0​3​.​0​3​7​​​​.​ Epub 2019/05/13.
of clinical documentation Burden among Physicians and Nurses Using 35. Wurster F, Fütterer G, Beckmann M, Dittmer K, Jaschke J, Köberlein-Neu J,
Electronic Health Records: a scoping review. J Am Med Inf Association: et al. The Analyzation of Change in Documentation due to the Introduc-
JAMIA. 2021;28(5):998–1008. https:/​/doi.or​g/10.10​93/j​amia/ocaa325. Epub tion of Electronic Patient Records in Hospitals-a systematic review. J Med
2021/01/13. Syst. 2022;46(8):54. https:/​/doi.or​g/10.10​07/s​10916-022-01840-0. Epub
31. Nicolay CR, Purkayastha S, Greenhalgh A, Benn J, Chaturvedi S, Phillips N, et 2022/07/06.
al. Systematic review of the application of Quality Improvement method-
ologies from the Manufacturing Industry to Surgical Healthcare. Br J Surg.
2012;99(3):324–35. https:/​/doi.or​g/10.10​02/b​js.7803. Epub 2011/11/22. Publisher’s note
32. Tang B, Lin D, Zhang F, Yan M, Shao A. The Plan-Do-Check-Action Plan Springer Nature remains neutral with regard to jurisdictional claims in
helps improve the quality of the standardized training of Resident published maps and institutional affiliations.
Physicians: an analysis of the results of the First Pass Rate. Front Public
Health. 2020;8:598774. https:/​/doi.or​g/10.33​89/f​pubh.2020.598774. Epub
2021/03/13.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:

1. use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
2. use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
3. falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
4. use bots or other automated methods to access the content or redirect messages
5. override any security feature or exclusionary protocol; or
6. share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at

[email protected]