This is a randomized non-blinded controlled trial of a standard note template versus a redesigned note template using a simulated patient encounter and the electronic medical record.
Residents documented the simulated patient encounter using one of two templates. The standard template was based on the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment section, and deemphasized elements not related to the current presentation.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
36
Residents assigned to document with new progress note template
Residents assigned to document with standard progress note template
Johns Hopkins Outpatient Center
Baltimore, Maryland, United States
Note length
Note length in line count.
Time frame: Duration of note entry, up to 2 hours
Time to note completion
Time to note completion in minutes.
Time frame: Duration of note entry, up to 2 hours
Note evaluation by authors using a likert scale
Likert-scale survey instrument evaluating perceived organization, structure, and efficiency of note.
Time frame: Immediately after note entry, up to 1 hour
Note evaluation by reviewers using the Physician Documentation Quality Instrument
Physician Documentation Quality Instrument (PDQI-9) - validated note quality scale composed of 9 metrics. 1 is not at all. 5 is extremely.
Time frame: Within 1 year
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