Resident Notes in an Electronic Health Record

Megan Aylor, Emily M. Campbell, Christiane Winter, Carrie Phillipi

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre- and 610 notes post-template introduction were identified. Note length was 263 characters shorter (P =.004) and mean end time was 73 minutes later (P <.0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template (P <.01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR's contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.

Original languageEnglish (US)
Pages (from-to)257-262
Number of pages6
JournalClinical Pediatrics
Volume56
Issue number3
DOIs
StatePublished - Mar 1 2017

Fingerprint

Electronic Health Records
Documentation
Focus Groups
Inpatients
Surveys and Questionnaires

Keywords

  • documentation
  • electronic health record
  • medical record
  • notes
  • resident
  • template

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Cite this

Resident Notes in an Electronic Health Record. / Aylor, Megan; Campbell, Emily M.; Winter, Christiane; Phillipi, Carrie.

In: Clinical Pediatrics, Vol. 56, No. 3, 01.03.2017, p. 257-262.

Research output: Contribution to journalArticle

Aylor, Megan ; Campbell, Emily M. ; Winter, Christiane ; Phillipi, Carrie. / Resident Notes in an Electronic Health Record. In: Clinical Pediatrics. 2017 ; Vol. 56, No. 3. pp. 257-262.
@article{2c1aa6505deb4134acbb1437a97f05e1,
title = "Resident Notes in an Electronic Health Record",
abstract = "Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre- and 610 notes post-template introduction were identified. Note length was 263 characters shorter (P =.004) and mean end time was 73 minutes later (P <.0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template (P <.01). Among survey respondents, 89{\%} liked the new note templates, 78{\%} stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR's contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.",
keywords = "documentation, electronic health record, medical record, notes, resident, template",
author = "Megan Aylor and Campbell, {Emily M.} and Christiane Winter and Carrie Phillipi",
year = "2017",
month = "3",
day = "1",
doi = "10.1177/0009922816658651",
language = "English (US)",
volume = "56",
pages = "257--262",
journal = "Clinical Pediatrics",
issn = "0009-9228",
publisher = "SAGE Publications Inc.",
number = "3",

}

TY - JOUR

T1 - Resident Notes in an Electronic Health Record

AU - Aylor, Megan

AU - Campbell, Emily M.

AU - Winter, Christiane

AU - Phillipi, Carrie

PY - 2017/3/1

Y1 - 2017/3/1

N2 - Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre- and 610 notes post-template introduction were identified. Note length was 263 characters shorter (P =.004) and mean end time was 73 minutes later (P <.0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template (P <.01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR's contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.

AB - Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre- and 610 notes post-template introduction were identified. Note length was 263 characters shorter (P =.004) and mean end time was 73 minutes later (P <.0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template (P <.01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR's contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.

KW - documentation

KW - electronic health record

KW - medical record

KW - notes

KW - resident

KW - template

UR - http://www.scopus.com/inward/record.url?scp=85014490060&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85014490060&partnerID=8YFLogxK

U2 - 10.1177/0009922816658651

DO - 10.1177/0009922816658651

M3 - Article

VL - 56

SP - 257

EP - 262

JO - Clinical Pediatrics

JF - Clinical Pediatrics

SN - 0009-9228

IS - 3

ER -