title: How physicians document outpatient visit notes in an electronic health record.
abstract: BACKGROUND
  Clinical documentation, an essential process within electronic health records (EHRs), takes a significant amount of clinician time. How best to optimize documentation methods to deliver effective care remains unclear.
  
  
  OBJECTIVE
  We evaluated whether EHR visit note documentation method was influenced by physician or practice characteristics, and the association of physician satisfaction with an EHR notes module.
  
  
  METHODS
  We surveyed primary care physicians (PCPs) and specialists, and used EHR and provider data to perform a multinomial logistic regression of visit notes from 2008. We measured physician documentation method use and satisfaction with an EHR notes module and determined the relationship between method and physician and practice characteristics.
  
  
  RESULTS
  Of 1088 physicians, 85% used a single method to document the majority of their visits. PCPs predominantly documented using templates (60%) compared to 34% of specialists, while 38% of specialists predominantly dictated. Physicians affiliated with academic medical centers (OR 1.96, CI (1.23, 3.12)), based at a hospital (OR 1.57, 95% CI (1.04, 2.36)) and using the EHR for longer (OR 1.13, 95% CI (1.03, 1.25)) were more likely to dictate than use templates. Most physicians of 383 survey responders were satisfied with the EHR notes module, regardless of their preferred documentation method.
  
  
  CONCLUSIONS
  Physicians predominantly utilized a single method of visit note documentation and were satisfied with their approach, but the approaches they chose varied. Demographic characteristics were associated with preferred documentation method. Further research should focus on why variation exists, and the quality of the documentation resulting from different methods used.
authors.affiliation: Partners Healthcare Systems, Boston, MA, USA.
authors.forename: Stephanie E
authors.initials: SE
authors.lastname: Pollard
authors.forename: Pamela M
authors.initials: PM
authors.lastname: Neri
authors.forename: Allison R
authors.initials: AR
authors.lastname: Wilcox
authors.forename: Lynn A
authors.initials: LA
authors.lastname: Volk
authors.forename: Deborah H
authors.initials: DH
authors.lastname: Williams
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Schiff
authors.forename: Harley Z
authors.initials: HZ
authors.lastname: Ramelson
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D004282:Documentation / Q000639:trends*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010045:Outpatients / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care; D011787:Quality of Health Care