A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians

Abstract

Objective The objective of this study is to understand physicians’ usage of inpatient notes by (i) ascertaining different clinical note-entry and reading/retrieval styles in two different and widely used Electronic Health Record (EHR) systems, (ii) extrapolating potential factors leading to adoption of various note-entry and reading/retrieval styles and (iii) determining the amount of time to task associated with documenting different types of clinical notes. Methods In order to answer “what” and “why” questions on physicians’ adoption of certain note-entry and reading/retrieval styles, an ethnographic study entailing Internal Medicine residents, with a mixed data analysis approach was performed. Participants were observed interacting with two different EHR systems in inpatient settings. Data was collected around the use and creation of History and Physical (H&P) notes, progress notes and discharge summaries. Results The highest variability in template styles was observed with progress notes and the least variability was within discharge summaries, while note-writing styles were most consistent for H&P notes. The first section to be read in a H&P and progress note were the Chief Complaint and Assessment & Plan sections, respectively. The greatest note retrieval variability, with respect to the order of how note sections were reviewed, was observed with H&P and progress notes. Physician preference for adopting a certain reading/retrieval order appeared to be a function of what best fits their workflow while fulfilling the stimulus demands. The time spent entering H&P, discharge summaries and progress notes were similar in both EHRs. Conclusion This research study unveils existing variability in clinical documentation processes and provides us with important information that could help in designing a next generation EHR Graphical User Interface (GUI) that is more congruent with physicians’ mental models, task performance needs, and workflow requirements.

Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study

“…Even more interesting was the difference in actual “note” elements between scribes. This is consistent with findings from studies showing discrepancies between physicians in the content and quality of documentation in notes [ 19 , 20 ]. Thus, whereas this phenomenon is most likely not unique to scribes, it does imply that scribes may face the same issues that are found among other clinicians.…”

“…Notably, there was a paucity of overlap in content between the notes, with less than 40% of the documented plan items and diagnoses being common across the scribes. This is consistent with the observation that there is wide variability in the content of resident-physician-generated progress notes, where the primary author of the note (the resident) was also responsible for acquisition of the primary data and synthesizing that information into medical decision making [ 20 ]. This study suggests that similar issues may arise purely in the process of how our subjects communicate as members of an interprofessional team.…”

Copy-and-Paste in Medical Student Notes: Extent, Temporal Trends, and Relationship to Scholastic Performance

“…While some redundancy in the H þ P/patient summary comparison can be anticipated, 6,16 two sections suggest a degree of pervasiveness that may be counterproductive. In nearly 50% of SPIs, the allergy section was entirely redundant, meaning that no changes were made to the auto-imported text.…”

Usability Evaluation of Electronic Health Record System around Clinical Notes Usage–An Ethnographic Study

“…Clinical notes may be difficult to find, time consuming to enter, contain poorly formatted information that is difficult to read, incorporate erroneous or out-of-date information, or lack standardized content display within EHR systems. 30,31 Despite these known usability problems, EHR clinical notes remain essential resources for clinicians who use them to communicate, summarize, and synthesize patient care information for decision making. Physicians and other clinicians are challenged, both when entering information into and retrieving information from clinical notes, as current EHRs may not sufficiently support these tasks.…”