Report: Best practice programs foster better physician notes

Julie Spitzer - Print  | 

Physicians take higher-quality and more efficient notes when they receive education and guidelines that emphasis note-taking best practices, according to a UC-Los Angeles study.

For the study, Neveen El-Farra, MD, and Daniel Kahn, MD, distributed note-taking templates that incorporated best practices at four academic internal medicine residency programs. Residents received both a brief educational conference and the electronic progress note template, which included an inpatient checklist for documenting patient concerns, quality measures and discharge planning. The template offered physicians a way to minimize the use of common efficiency tools — including the auto-population of notes — and instead, encourage them to enter only relevant information.

The researchers found that physicians produced shorter, higher-quality notes within a short period of time.

"By limiting efficiency tools such as copying-forward and autofill, the progress notes were significantly improved for quality, were shorter in length and were completed more quickly," the study reads.

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