Assessing usage patterns of electronic clinical documentation templates.
Many vendors of electronic medical records support structured and free-text entry of clinical documents using configurable templates. At a healthcare institution comprising two large academic medical centers, a documentation management data mart and a custom, Web-accessible business intelligence application were developed to track the availability and usage of electronic documentation templates. For each medical center, template availability and usage trends were measured from November 2007 through February 2008. By February 2008, approximately 65,000 electronic notes were authored per week on the two campuses. One site had 934 available templates, with 313 being used to author at least one note. The other site had 765 templates, of which 480 were used. The most commonly used template at both campuses was a free text note called "Miscellaneous Nursing Note," which accounted for 33.3% of total documents generated at one campus and 15.2% at the other.
Vawdrey
David K
DK
Department of Biomedical Informatics, Columbia University, New York, NY, USA.
D000465:Algorithms; D001185:Artificial Intelligence; D004282:Documentation / Q000706:statistics & numerical data*; D016247:Information Storage and Retrieval / Q000379:methods*; D008487:Medical History Taking / Q000379:methods* / Q000706:statistics & numerical data*; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D009323:Natural Language Processing; D009518:New York; D010363:Pattern Recognition, Automated / Q000379:methods*; D013358:Subject Headings; D014481:United States; D014584:User-Computer Interface