An electronic documentation system improves the quality of admission notes: a randomized trial

Area of Science:

• Medical Informatics
• Clinical Documentation Improvement

Background:

• Concerns exist regarding structured electronic documentation systems potentially limiting expressivity and leading to lengthy, unreadable notes.
• Assessing the impact of electronic clinical documentation on the quality of patient admission notes is crucial for healthcare quality improvement.

Purpose of the Study:

• To evaluate the effect of an electronic clinical documentation system on the quality of admission notes for patients on a general medical unit.
• To compare the quality and content of electronic admission notes versus traditional handwritten paper notes.

Main Methods:

• A prospective randomized crossover study design was employed.
• Handwritten paper notes were compared to electronic notes generated using a semistructured electronic admission documentation system.
• The QNOTE instrument assessed clinical documentation quality, and word counts analyzed free-text sections.

Main Results:

• Overall note quality was significantly higher for electronic notes (mean 90) compared to paper notes (mean 69).
• The quality of free-text subsections, including History of Present Illness and Impression and Plan, was significantly better in electronic notes.
• The History of Present Illness section was substantially longer in electronic notes (mean 172.4 words) versus paper notes (mean 92.4 words).

Conclusions:

• Electronic admission documentation systems demonstrably enhance the overall quality of patient admission notes.
• The implementation of electronic systems led to improved quality of free-text content and increased author expressivity in these sections.