Impact of clinical note format on diagnostic accuracy and efficiency

Abstract

Background Clinician notes are structured in a variety of ways. This research pilot tested an innovative study design and explored the impact of note formats on diagnostic accuracy and documentation review time. Objective To compare two formats for clinical documentation (narrative format vs. list of findings) on clinician diagnostic accuracy and documentation review time. Method Participants diagnosed written clinical cases, half in narrative format, and half in list format. Diagnostic accuracy (defined as including correct case diagnosis among top three diagnoses) and time spent processing the case scenario were measured for each format. Generalised linear mixed regression models and bias-corrected bootstrap percentile confidence intervals for mean paired differences were used to analyse the primary research questions. Results Odds of correctly diagnosing list format notes were 26% greater than with narrative notes. However, there is insufficient evidence that this difference is significant (75% CI 0.8–1.99). On average the list format notes required 85.6 more seconds to process and arrive at a diagnosis compared to narrative notes (95% CI -162.3, −2.77). Of cases where participants included the correct diagnosis, on average the list format notes required 94.17 more seconds compared to narrative notes (75% CI -195.9, −8.83). Conclusion This study offers note format considerations for those interested in improving clinical documentation and suggests directions for future research. Balancing the priority of clinician preference with value of structured data may be necessary. Implications This study provides a method and suggestive results for further investigation in usability of electronic documentation formats.

Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

“…Several authors Payton et al, 2023; 2023) reported the need for balance between structured and narrative forms of documentation and that highly structured formats (a feature of EHRs) can limit usability. Several authors highlighted multifactor influences on CDI, including personal, systemic and environmental Lövestam et al, 2022;.…”

“…Standardisation to address CDI-related issues (e.g. ambiguous terminology, inconsistent, incomplete and variability in diagnosis documentation) was recommended by Alonso et al (2020) and Payton et al (2023). described issues arising from documentation that is ambiguous when terms such as "probable," "likely" and "query" are used.…”

“…The significance of clinical coding as impacted by CDI has been alluded to in a number of articles in the VSI collection that describe issues experienced by specific clinical programmes where information was not available in a form that supported the programme. Strategies to address the limitations of administrative coded data and lack of specificity in support of CDI have been proposed by Duke et al (2022), Payton et al (2023) and . In their editorial on the emergence of health information in aged care, Loggie and Davis (2023) discussed needed improvements in clinical documentation related specifically to the aged care sector.…”

“…While challenges exist, there is clear potential and interest in optimising data captured as electronic forms of clinical documentation; however, its integrity remains critical. Several articles considered the usability of EHR documentation from clinician perspectives (Lloyd et al, 2023;Payton et al, 2023). Lloyd et al (2023) focused on situational factors impacting clinicians such as increasing complexity, work pressures, burnout and highlighting challenges identified by clinicians related to EMR such as usability, lack of intuitiveness, complexity, difficulties communicating with primary and other care sectors and time taken to perform clinical tasks.…”