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A Prescription for Note Bloat: An Effective Progress Note Template.

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Summary
This summary is machine-generated.

An educational session and progress note template improved electronic health record (EHR) documentation quality, reduced note length, and increased timeliness among intern physicians.

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Area of Science:

  • Medical Informatics
  • Healthcare Quality Improvement
  • Clinical Documentation

Background:

  • Electronic health records (EHRs) are widely used in US hospitals.
  • Concerns exist regarding the impact of EHR adoption on clinical documentation quality.
  • Optimizing EHR documentation is crucial for efficient healthcare delivery.

Purpose of the Study:

  • To evaluate the effectiveness of an educational intervention combined with a progress note template.
  • To assess the impact on the quality, length, and timeliness of physician progress notes.
  • To identify best practices for improving EHR documentation.

Main Methods:

  • A multicenter, nonrandomized prospective trial was conducted across four academic hospitals.
  • Intern physicians received an educational lecture and utilized a new progress note template.
  • Note quality was assessed using a general impression score, the PDQI-9, and a competency questionnaire.

Main Results:

  • A significant improvement in overall note quality was observed, including all domains of the PDQI-9.
  • Key competencies such as documenting relevant data and discussing discharge plans showed improvement.
  • Progress notes were 25% shorter and signed 1.3 hours earlier on average.

Conclusions:

  • A bundled intervention significantly enhanced the quality of EHR progress notes.
  • The intervention led to a reduction in note length and improved timeliness of completion.
  • This approach offers a scalable solution for improving clinical documentation in academic medical centers.