Clinical Documentation in Electronic Health Record Systems: Analysis of Similarity in Progress Notes from Consecutive Outpatient Ophthalmology Encounters

Abigail E. Huang, Michelle Hribar, Isaac H. Goldstein, Brad Henriksen, Wei Chun Lin, Michael Chiang

Research output: Contribution to journalArticle

3 Scopus citations

Abstract

Content importing technology enables duplication of large amounts of clinical text in electronic health record (EHR) progress notes. It can be difficult to find key sections such as Assessment and Plan in the resulting note. To quantify the extent of text length and duplication, we analyzed average ophthalmology note length and calculated novelty of each major note section (Subjective, Objective, Assessment, Plan, Other). We performed a retrospective chart review of consecutive note pairs and found that the average encounter note was 1182 ± 374 words long and less than a quarter of words changed between visits. The Plan note section had the highest percentage of change, and both the Assessment and Plan sections comprised a small fraction of the full note. Analysis of progress notes by section and unique content helps describe physician documentation activity and inform best practices and EHR design recommendations.

Original languageEnglish (US)
Pages (from-to)1310-1318
Number of pages9
JournalAMIA ... Annual Symposium proceedings. AMIA Symposium
Volume2018
StatePublished - Jan 1 2018

ASJC Scopus subject areas

  • Medicine(all)

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