Improving Provider Documentation Compliance in Adult BMI Screening and Follow-up at a Federally Qualified Health Center

The rising obesity rates in the United States (U.S.) highlight the need for a standardized obesity screening and intervention plan in primary care. Adult Body Mass Index (BMI) screening and follow-up is a Uniformed Data System (UDS) quality metric for Federally Qualified Health Centers (FQHCs), requiring consistent documentation for compliance and funding. A literature review identified an electronic health record (EHR) support tool as an effective method to standardized BMI screening and improve provider documentation. This quality improvement (QI) project implemented an EHR support tool to improve BMI screening compliance among primary care providers (PCPs). Institutional review board (IRB) approval and written informed consent were obtained, and educational in-services were conducted. Guided by the Diffusion of Innovation theory, weekly participant checks assessed acceptance and adoption of the intervention. A chart audit of 843 eligible patient records showed the EHR support tool was utilized in 191 charts (22.66%), while a BMI diagnosis code was recorded in 235 charts (27.88%). Findings indicated that the standardized BMI screening process did not significantly improve provider documentation compliance, with short appointment times and multiple patient complaints cited as barriers. Despite these challenges, implementing a structured BMI screening process remains critical for securing FQHC federal funding and early obesity intervention.