title: Resident Notes in an Electronic Health Record.
abstract: Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre- and 610 notes post-template introduction were identified. Note length was 263 characters shorter ( P = .004) and mean end time was 73 minutes later ( P < .0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template ( P < .01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR's contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.
authors.affiliation: 1 Oregon Health & Science University, Portland, OR, USA.
authors.forename: Megan
authors.initials: M
authors.lastname: Aylor
authors.affiliation: 1 Oregon Health & Science University, Portland, OR, USA.
authors.forename: Emily M
authors.initials: EM
authors.lastname: Campbell
authors.affiliation: 1 Oregon Health & Science University, Portland, OR, USA.
authors.forename: Christiane
authors.initials: C
authors.lastname: Winter
authors.affiliation: 1 Oregon Health & Science University, Portland, OR, USA.
authors.forename: Carrie A
authors.initials: CA
authors.lastname: Phillipi
mesh_terms: D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D006801:Humans; D007396:Internship and Residency
keywords: documentation; electronic health record; medical record; notes; resident; template