Standardizing Resident Point-of-Care Ultrasound Education and Documentation: A Quality Improvement Initiative.

BACKGROUND: Point-of-care ultrasound (POCUS) is an effective and increasingly important bedside tool for evaluating cardiac function, pulmonary congestion, and volume status in patients. Despite growing evidence supporting its use, adoption among internal medicine residents remains inconsistent given workflow barriers, lack of standardized documentation, and variable confidence in image acquisition and interpretation. PROJECT RATIONALE: We sought to identify barriers to resident POCUS use and implement a sustainable intervention to improve adoption and documentation during evaluation of patients through a structured educational and workflow intervention. PROJECT SUMMARY: A multidisciplinary team conducted a quality improvement initiative on an internal medicine teaching service. Baseline resident surveys and root-cause analysis identified lack of workflow integration and standardized documentation as major barriers. Interventions included development of an electronic medical record (EMR) SmartPhrase (.POCUSReport) and faculty-led education. A total of 23 residents completed baseline surveys and 8 completed postintervention surveys. After implementation, 87% reported improved integration of POCUS into patient assessment, and 75% requested additional training. EMR analytics identified 30 documented POCUS examinations performed by 11 unique residents. TAKE-HOME MESSAGES: Combining workflow integration, standardized documentation, and focused education can increase resident adoption of POCUS. Simple EMR-based interventions provide a scalable strategy for implementing bedside ultrasound in academic training programs.