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Related Experiment Video

Updated: Dec 9, 2025

E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

Published on: August 1, 2019

Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering)

Jeremy A Epstein¹, Joseph Cofrancesco², Mary Catherine Beach²

¹Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, Baltimore, MD, USA. Epstein@jhmi.edu.

Journal of General Internal Medicine

|September 9, 2020

Summary

A redesigned clinical note template resulted in shorter, more visually appealing notes for residents. However, faculty reviewers found the redesigned template less accurate and useful, though better organized, with no difference in overall quality.

Keywords:

Clinical documentation Note quality Note template

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Area of Science:

Medical Informatics
Clinical Documentation Improvement
Healthcare Quality

Background:

Optimizing clinical note quality is crucial for effective patient care and medical education.
Evaluating the impact of electronic health record (EHR) note template design on documentation quality is essential.

Purpose of the Study:

To compare the quality of clinical notes generated using a standard template versus a redesigned template.
To utilize a novel randomized clinical simulation process to assess note template effectiveness.

Main Methods:

A randomized controlled trial involving PGY 1-3 Internal Medicine residents.
Residents documented a simulated patient encounter using either a standard or redesigned note template.
Note quality was assessed by resident authors and faculty reviewers using various metrics.

Main Results:

The redesigned template produced significantly shorter notes (103 vs. 285 lines) with no increase in completion time.
Residents perceived the new template as more visually appealing and less cluttered.
Faculty reviewers rated the redesigned notes as better organized but less up-to-date, accurate, and useful compared to the standard template.

Conclusions:

While residents favored the redesigned note template for its brevity and clarity, faculty assessment indicated potential trade-offs in accuracy and usefulness.
The study highlights the importance of comprehensive evaluation, including both resident and faculty perspectives, when redesigning clinical documentation templates.
A simulated clinical encounter provides a valuable method for assessing note template performance prior to implementation in practice.