The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency.
Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation. Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5% and 60% to 100% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3% to 0% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming electronic progress note.
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
George J
GJ
Kargul
Scott M
SM
Wright
Amy M
AM
Knight
Mary T
MT
McNichol
Jeffrey M
JM
Riggio
D004282:Documentation / Q000379:methods / Q000592:standards; D004526:Efficiency; D057286:Electronic Health Records / Q000458:organization & administration* / Q000592:standards; D006785:Hospitals, University / Q000458:organization & administration / Q000592:standards; D006801:Humans; D015143:Philadelphia; D010820:Physicians / Q000458:organization & administration* / Q000592:standards; D015397:Program Evaluation; D011787:Quality of Health Care / Q000458:organization & administration / Q000592:standards