Frequent but fragmented: use of note templates to document outpatient visits at an academic health center.
Recent changes to billing policy have reduced documentation requirements for outpatient notes, providing an opportunity to rethink documentation workflows. While many providers use templates to write notes-whether to insert short phrases or draft entire notes-we know surprisingly little about how th...
| Publicado en: | Journal of the American Medical Informatics Association Vol. 29; no. 1; pp. 137 - 142 |
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| Autores principales: | , |
| Formato: | research tables/charts Journal Article |
| Publicado: |
Oxford University Press / USA
Jan2022
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=154359995&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 154359995 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 10675027 FZ9 jtl: Journal of the American Medical Informatics Association issn: 10675027 maglogo: N pubinfo: dt: Jan2022 vid: 29 iid: 1 pid: 622 pub: Oxford University Press / USA artinfo: ui: 154359995 154359995 NLM34664655 154359995 10.1093/jamia/ocab230 NLM34664655 154359995 ppf: 137 ppct: 5 formats: tig: atl: Frequent but fragmented: use of note templates to document outpatient visits at an academic health center. aug: au: Rule, Adam Hribar, Michelle R affil: Information School, University of Wisconsin–Madison , Madison, Wisconsin, USA sug: subj: Outpatients Cross Sectional Studies Retrospective Design Documentation Human Comparative Studies Multicenter Studies Evaluation Research Validation Studies Funding Source ab: Recent changes to billing policy have reduced documentation requirements for outpatient notes, providing an opportunity to rethink documentation workflows. While many providers use templates to write notes-whether to insert short phrases or draft entire notes-we know surprisingly little about how these templates are used in practice. In this retrospective cross-sectional study, we observed the templates that primary providers and other members of the care team used to write the provider progress note for 2.5 million outpatient visits across 52 specialties at an academic health center between 2018 and 2020. Templates were used to document 89% of visits, with a median of 2 used per visit. Only 17% of the 100 230 unique templates were ever used by more than one person and most providers had their own full-note templates. These findings suggest template use is frequent but fragmented, complicating template revision and maintenance. Reframing template use as a form of computer programming suggests ways to maintain the benefits of personalization while leveraging standardization to reduce documentation burden. pubtype: Academic Journal doctype: research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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