Evaluating the impact of structured text and templates in ambulatory nursing

This evaluation looks at the use of templates for entering structured text nursing notes that generate both a legal text note that is the chart record and an underlying coded form of the note to support analysis and research. This study reflects the first phase of a prototype project of an integrated, computerized health record. Templates are notes that have been prewritten using a standard clinical vocabulary. Templates can be used as the basis of a new clinical note and can be either signed unchanged or modified to represent variations in clinical presentation. The prototype setting is a Primary Care clinic where both physicians and nurses are using the computer to enter clinical notes. In the prototype clinic team, nursing utilized the CPR for 100% of all documentation from day one. Use of templates was found to be the most frequent method of initiating a note.