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Using Electronic Health Record Meta-Data to Identify Variation in Trainee Progress Note Writing Patterns: Opportunity
Karen Trang1, Logan Pierce2, Elizabeth C Wick1
1Department of Surgery, University of California San Francisco, San Francisco, California.
Filing inpatient surgical progress notes earlier improves their visibility and use by collaborating healthcare teams. Timely notes enhance communication and efficiency in patient care.
Area of Science:
- Medical Informatics
- Healthcare Communication
- Surgical Patient Care
Background:
- Daily progress notes are crucial for documenting patient diagnoses, conditions, and interventions in inpatient settings.
- These notes serve as essential communication tools among healthcare providers.
- Understanding patterns in progress note filing and usage is vital for optimizing healthcare delivery.
Purpose of the Study:
- To analyze the patterns of progress note filing and subsequent use within general surgical services.
- To determine the impact of filing times on the viewership of progress notes by multidisciplinary teams.
- To identify potential areas for improving the timeliness and efficiency of progress note completion.
Main Methods:
- Utilized electronic health record (EHR) data warehouse for progress notes signed between July 2020 and July 2021.
- Included notes authored by resident physicians and advanced practice providers (APPs), excluding those filed on surgery days.
- Measured note viewership by various disciplines using EHR access logs, targeting 10 am for note completion.
Main Results:
- Analyzed 8384 progress notes, with 49% authored by trainees.
- 53% of notes were filed before 10 am, 44% between 10 am and 6 pm, and 3% after 6 pm.
- Notes filed before 10 am received significantly more same-day views (11.8) compared to those filed after 10 am (8.4).
Conclusions:
- Progress notes are a significant communication resource despite being a perceived burden by trainees.
- Earlier filing of progress notes correlates with increased viewership by collaborating disciplines.
- Addressing barriers to timely note completion can enhance communication and efficiency in inpatient surgical care.
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