How physicians document outpatient visit notes in an electronic health record

Area of Science:

• Health Informatics
• Clinical Documentation
• Electronic Health Records (EHRs)

Background:

• Clinical documentation is a time-intensive but essential EHR process.
• Optimizing documentation methods for effective care delivery requires further investigation.

Purpose of the Study:

• To evaluate if physician or practice characteristics influence EHR visit note documentation methods.
• To assess physician satisfaction with EHR notes modules.

Main Methods:

• Surveyed primary care physicians (PCPs) and specialists.
• Utilized EHR and provider data for multinomial logistic regression analysis.
• Measured documentation method use and satisfaction with EHR notes modules.

Main Results:

• 85% of physicians used a single documentation method.
• PCPs favored templates (60%), while specialists often dictated (38%).
• Academic affiliation, hospital-based practice, and longer EHR use correlated with dictation.

Conclusions:

• Physicians predominantly use a single documentation method and report satisfaction.
• Documentation method choice is associated with physician and practice demographics.
• Future research should explore the reasons for method variation and its impact on documentation quality.