Physicians' style of note-taking could affect the quality of care they provide, according to a study published in the Journal of the American Medical Informatics Association.
The study examined interactions between 7,000 coronary artery disease and diabetes patients with 234 primary care physicians. Of those physicians, 9 percent dictated their notes, 29 percent used structured documentation and 62 percent typed free text notes. Structured documentation involves standardize forms, while dictating involves reading information over a phone, which is transcribed to an electronic health record.
The study found the quality of care "appeared significantly worse" for dictating physicians than those who used the other two documentation styles for three of 15 measures. Those measures involved the documentation of patients' antiplatelet medication, tobacco use documentation and diabetic eye exam. Dictators did not have a higher quality of care than physicians using the other two documentation styles on any measures.
Structured documenters were associated with better quality of care for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam), and free-typers were associated with better quality of care for one measure (influenza vaccination).
The study authors concluded that physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.
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The study examined interactions between 7,000 coronary artery disease and diabetes patients with 234 primary care physicians. Of those physicians, 9 percent dictated their notes, 29 percent used structured documentation and 62 percent typed free text notes. Structured documentation involves standardize forms, while dictating involves reading information over a phone, which is transcribed to an electronic health record.
The study found the quality of care "appeared significantly worse" for dictating physicians than those who used the other two documentation styles for three of 15 measures. Those measures involved the documentation of patients' antiplatelet medication, tobacco use documentation and diabetic eye exam. Dictators did not have a higher quality of care than physicians using the other two documentation styles on any measures.
Structured documenters were associated with better quality of care for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam), and free-typers were associated with better quality of care for one measure (influenza vaccination).
The study authors concluded that physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.
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