BACKGROUND AND PURPOSE:

• The advent of electronic health records over the past decade has led to concerns regarding clinician time being diverted toward writing and reviewing documentation at the expense of direct patient care
• Rule et al. (JAMA Network Open, 2021) measured the changes in the length and redundancy of outpatient progress notes across multiple medical specialties

METHODS:

• Cross-sectional study (between 2009 and 2018)
• Participants
  • Clinicians and staff who wrote outpatient progress notes
• Exposures
  • Use of a comprehensive electronic health record to document patient care
• Primary outcomes
  • Note length
  • Note redundancy (the proportion of text identical to the patient’s last notes)
  • Percentage of templated, copied, or directly typed note text

RESULTS:

• 2,704,800 notes | 6228 primary authors | 46 specialties
• Median note length and redundancy increased between 2009 and 2018
  • Note length increased 60.1% (99% CI, 46.7 to 75.2)
    • 2009: median (IQR) words 401 (225 to 660)
    • 2018: median (IQR) words 642 (399 to 1007)
  • Note redundancy increased 10.9 percentage points (99% CI, 7.5 to 14.3)
    • 2009: 47.9%
    • 2018: 58.8%
• Notes written in 2018 consisted of mostly templated or copied text
  • Directly typed text: 29.4% (99% CI, 28.2 to 30.7)
  • Templated or copied text: 70.6%
• Notes with higher proportions of templated or copied text were significantly longer and more redundant, with each 1% increase in the proportion of copied or templated note text being associated with a
  • 1.5% increase in note length (95% CI, 1.5 to 1.5)
  • 1.6% increase in note redundancy (95% CI, 1.6 to 1.6)
• Compared to more senior authors, the following wrote significantly longer notes
  • Residents and fellows: 26.3% (95% CI, 25.8 to 26.7)
  • Recent hires: 1.8% for each year later (95% CI, 1.3 to 2.4)

CONCLUSION:

• Patient care notes have become longer and more redundant since the adoption of electronic health records in 2009
  • Most note text is templated or copied
  • Residents, fellows, and more recent hires write significantly longer notes
• The authors state

Templates can reduce documentation time and increase standardization, but can also add potentially irrelevant information or introduce errors, as when used to insert default examination findings which were not actually observed

Learn More – Primary Sources:

Length and Redundancy of Outpatient Progress Notes Across a Decade at an Academic Medical Center

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