BACKGROUND: This is the first randomized controlled trial evaluating the impact of note template design on note quality using a simulated patient encounter and a validated assessment tool. OBJECTIVE: To compare note quality between two different templates using a novel randomized clinical simulation process. DESIGN: A randomized non-blinded controlled trial of a standard note template versus redesigned template. PARTICIPANTS: PGY 1-3 IM residents. INTERVENTIONS: Residents documented the simulated patient encounter using one of two templates. The standard template was modeled after the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment, and deemphasized less useful elements. MAIN MEASURES: Note length; time to note completion; note template evaluation by resident authors; note evaluation by faculty reviewers. KEY RESULTS: 36 residents participated, 19 randomized to standard template, 17 to new. New template generated shorter notes (103 vs 285 lines, p < 0.001) that took the same time to complete (19.8 vs 21.6 min, p = 0.654). Using a 5-point Likert scale, residents considered new notes to have increased visual appeal (4 vs 3, p = 0.05) and less redundancy and clutter (4 vs 3, p = 0.006). Overall template satisfaction was not statistically different. Faculty reviewers rated the standard note more up-to-date (4.3 vs 2.7, p = 0.001), accurate (3.9 vs 2.6, p = 0.003), and useful (4 vs 2.8, p = 0.002), but less organized (3.3 vs 4.5, p < 0.001). Total quality was not statistically different. CONCLUSIONS: Residents rated the new note template more visually appealing, shorter, and less cluttered. Faculty reviewers rated both note types equivalent in the overall quality but rated new notes inferior in terms of accuracy and usefulness though better organized. This study demonstrates a novel method of a simulated clinical encounter to evaluate note templates before the introduction into practice. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04333238

We report the case of a 31-year-old male with recurrent episodes of acute pancreatitis, subsequently discovered to have a rare type III choledochal cyst, also termed a choledochocele. This case demonstrates the utility of multiple imaging techniques to diagnose the correct etiology of the patient's pancreatitis, as well as to appropriately plan surgical intervention. For many years, endoscopic retrograde cholangeopancreatography has been the gold-standard for diagnosis of type III choledochal cysts; this procedure, however, carries a significant degree of morbidity and may perhaps be circumvented with the advent of advanced imaging techniques that allow for visualization of the intraduodenal portion of the biliary tract. In this case, CT and MR imaging demonstrated a spherical, cyst-like structure extending from the pancreatic duct into the second part of the duodenum, suggestive of a choledochocele. Presence of the choledochocele and its exact anatomy were confirmed with ERCP. This imaging, in combination with the appropriate clinical constellation of symptoms, enabled correct identification of the etiology of the patient's unexplained recurrent episodes of pancreatitis, allowing for appropriate and curative surgical intervention.

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