Frequent but fragmented: use of note templates to document outpatient visits at an academic health center

Research output: Contribution to journalArticlepeer-review

Abstract

Recent changes to billing policy have reduced documentation requirements for outpatient notes, providing an opportunity to rethink documentation workflows. While many providers use templates to write notes-whether to insert short phrases or draft entire notes-we know surprisingly little about how these templates are used in practice. In this retrospective cross-sectional study, we observed the templates that primary providers and other members of the care team used to write the provider progress note for 2.5 million outpatient visits across 52 specialties at an academic health center between 2018 and 2020. Templates were used to document 89% of visits, with a median of 2 used per visit. Only 17% of the 100 230 unique templates were ever used by more than one person and most providers had their own full-note templates. These findings suggest template use is frequent but fragmented, complicating template revision and maintenance. Reframing template use as a form of computer programming suggests ways to maintain the benefits of personalization while leveraging standardization to reduce documentation burden.

Original languageEnglish (US)
Pages (from-to)137-141
Number of pages5
JournalJournal of the American Medical Informatics Association : JAMIA
Volume29
Issue number1
DOIs
StatePublished - Dec 28 2021
Externally publishedYes

Keywords

  • clinical documentation
  • electronic health records
  • note templates

ASJC Scopus subject areas

  • Health Informatics

Fingerprint

Dive into the research topics of 'Frequent but fragmented: use of note templates to document outpatient visits at an academic health center'. Together they form a unique fingerprint.

Cite this