Impact of clinical note format on diagnostic accuracy and efficiency

Area of Science:

• Medical Informatics
• Clinical Documentation
• Health Informatics

Background:

• Clinician notes exhibit diverse structures, impacting clinical workflows.
• This pilot study investigated novel designs for clinical documentation.
• The research explored how note formats influence diagnostic precision and review duration.

Purpose of the Study:

• To evaluate the comparative impact of narrative versus list-based clinical documentation formats.
• To assess effects on clinician diagnostic accuracy.
• To measure the influence on documentation review time.

Main Methods:

• Participants diagnosed clinical cases presented in either narrative or list formats.
• Diagnostic accuracy was assessed by the inclusion of the correct diagnosis within the top three.
• Time spent processing cases and statistical analysis using generalized linear mixed models were employed.

Main Results:

• List format notes showed a 26% higher odds of correct diagnosis, though not statistically significant (75% CI 0.8-1.99).
• List format notes required an average of 85.6 seconds longer for diagnosis (95% CI -162.3, -2.77).
• Cases with correct diagnoses in list format took 94.17 seconds longer to process (75% CI -195.9, -8.83).

Conclusions:

• Note format significantly influences diagnostic accuracy and review time.
• Considerations for improving clinical documentation include balancing clinician preference with structured data.
• The study provides a methodology and preliminary findings for electronic documentation format usability research.