Clinical Documentation
Conditions
Keywords
Progress note, Note template, Electronic medical record, Note quality
Brief summary
This is a randomized non-blinded controlled trial of a standard note template versus a redesigned note template using a simulated patient encounter and the electronic medical record.
Detailed description
Residents documented the simulated patient encounter using one of two templates. The standard template was based on the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment section, and deemphasized elements not related to the current presentation.
Interventions
OTHERStandard progress note template
Residents assigned to document with standard progress note template
OTHERNew progress note template
Residents assigned to document with new progress note template
Sponsors
Johns Hopkins University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
OTHER
Masking
NONE
Eligibility
Sex/Gender
ALL
Healthy volunteers
Yes
Inclusion criteria
* Residents who had open visit slots during their outpatient clinic time
Exclusion criteria
* None
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Note length | Duration of note entry, up to 2 hours | Note length in line count. |
| Time to note completion | Duration of note entry, up to 2 hours | Time to note completion in minutes. |
| Note evaluation by authors using a likert scale | Immediately after note entry, up to 1 hour | Likert-scale survey instrument evaluating perceived organization, structure, and efficiency of note. |
| Note evaluation by reviewers using the Physician Documentation Quality Instrument | Within 1 year | Physician Documentation Quality Instrument (PDQI-9) - validated note quality scale composed of 9 metrics. 1 is not at all. 5 is extremely. |
Countries
United States
Outcome results
None listed