Background/Purpose: Prescribing methotrexate,is common practice in rheumatology. Appropriate medication counselling and documentation is important. In our province, as per thephysician regulatory body the College of Physicians and Surgeons of Ontario (CPSO), it is mandated that informed consent is obtained before a treatment is provided. The CPSO provides guidelines on medication documentation in a patients health record. This includes specific risks communicated, any risks unique to the patient, risks of not treating and if consent was obtained.¹We believed that the consent process for DMARDs is not being documented according to these standards within our hospital.The aim of this project was to develop a Quality Improvement (QI) initiative to improve documentation of methotrexate initiation within our division, to >80%.

Methods: An audit of medication documentation was performed. We identified 10 sequential patients, from general rheumatology clinics, who started methotrexate from June 2018 – November 2021, when electronic health record (EHR) was introduced. We reviewed the health record from the time of initiation of methotrexate. We recorded if documentation was available in the EHR. Where available, we recorded if the documentation fully met CPSO standards (i.e. documented specific risks, risks unique to patient, risks of not treating/alternative treatments and agreement to commence therapy). If all factors were not documented, we recorded this as partial documentation. We organized an education session on CPSO guidelines and shared the results of our audit. We created a smart-phrase,in accordance with CPSO guidelines,for all patients starting methotrexate. A smart phrase is a tool in our EHR that allows users to link a paragraph to a simple phrase. For example, typing .mtxnotedocumentation populates the note with a detailed paragraph on methotrexate. This paragraph was reviewed by all prescribers within the division and revised. We placed visual reminders in clinics where documentation was performed. After implementation, we tracked use of the smart-phrase for a 4 month period to assess uptake.

Results: Of the ten patient charts identified in our audit, one had documentation that was fully adherent to CPSO guidelines (10%). Seven charts had partial documentation and two had no documentation other than stating that methotrexate was prescribed. This was in keeping with our initial hypothesis. In the first month of implementation of the smart-phrase, the number of charts with full documentation increased to 28%. Over the next 3 months, full documentation was measured at 80%, 50% and 75% for April, May and June respectively.

Conclusion: It is important to document precisely what was conveyed to the family when starting treatment in case there are later clinical concerns or medico-legal proceedings. Tools such as smart phrases, can increase documentation in a time efficient manner. Our intervention showed that once the smart phrase was available, it was used broadly. Ongoing education regarding the availability of the smart phrase will be needed to reach our goal of >80% compliance consistently. In the future, we plan to introduce similar smart-phrases for commonly prescribed biologic therapies.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-methotrexate-documentation-in-electronic-health-records-a-quality-improvement-initiative/