Observational studyInternational journal of medical informatics2016
A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians.
Observational study in International journal of medical informatics, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 18 papers, 1 of them a synthesis that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
18 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Clinicians' reasoning as reflected in electronic clinical note-entry and reading/retrieval: a systematic review and qualitative synthesis.Journal of the American Medical Informatics Association : JAMIA · 2019Pooled it
- Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial.Journal of general internal medicine · 2021Trial
- Electronic decision support for treatment of hospitalized smokers: A qualitative analysis of physicians' knowledge, attitudes, and practices.Drug and alcohol dependence · 2019Trial
- A Review on Artificial Intelligence as a Solution to Burnout in Interventional Radiology.Cardiovascular and interventional radiology · 2026Review
- Examining the Generalizability of Pretrained De-identification Transformer Models on Narrative Nursing Notes.Applied clinical informatics · 2024Article
- A human centered design approach to define and measure documentation quality using an EHR virtual simulation.PloS one · 2024Article
- Through the Narrative Looking Glass: Commentary on "Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review".Journal of medical Internet research · 2022Article
- Characterizing styles of clinical note production and relationship to clinical work hours among first-year residents.Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Electronic health record note review in an outpatient specialty clinic: who is looking?JAMIA open · 2021Article
- Building the evidence-base to reduce electronic health record-related clinician burden.Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Feeling and thinking: can theories of human motivation explain how EHR design impacts clinician burnout?Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era.Journal of medical Internet research · 2019Article
- Copy-and-Paste in Medical Student Notes: Extent, Temporal Trends, and Relationship to Scholastic Performance.Applied clinical informatics · 2019Article
- A Daily Hospital Progress Note that Increases Physician Usability of the Electronic Health Record by Facilitating a Problem-Oriented Approach to the Patient and Reducing Physician Clerical Burden.The Permanente journal · 2019Article
- Clinical Documentation in Electronic Health Record Systems: Analysis of Patient Record Review During Outpatient Ophthalmology Visits.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2018Article
- Usability Evaluation of Electronic Health Record System around Clinical Notes Usage-An Ethnographic Study.Applied clinical informatics · 2017Article
- Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study.JMIR medical informatics · 2017Article
- The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences.Journal of caring sciences · 2017Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
7 authors.
Funding
Abstract
objectiveThe objective of this study is to understand physicians' usage of inpatient notes by (i) ascertaining different clinical note-entry and reading/retrieval styles in two different and widely used Electronic Health Record (EHR) systems, (ii) extrapolating potential factors leading to adoption of various note-entry and reading/retrieval styles and (iii) determining the amount of time to task associated with documenting different types of clinical notes.
methodsIn order to answer "what" and "why" questions on physicians' adoption of certain-note-entry and reading/retrieval styles, an ethnographic study entailing Internal Medicine residents, with a mixed data analysis approach was performed. Participants were observed interacting with two different EHR systems in inpatient settings. Data was collected around the use and creation of History and Physical (H&P) notes, progress notes and discharge summaries.
resultsThe highest variability in template styles was observed with progress notes and the least variability was within discharge summaries, while note-writing styles were most consistent for H&P notes. The first sections to be read in a H&P and progress note were the Chief Complaint and Assessment & Plan sections, respectively. The greatest note retrieval variability, with respect to the order of how note sections were reviewed, was observed with H&P and progress notes. Physician preference for adopting a certain reading/retrieval order appeared to be a function of what best fits their workflow while fulfilling the stimulus demands. The time spent entering H&P, discharge summaries and progress notes were similar in both EHRs.
conclusionThis research study unveils existing variability in clinical documentation processes and provides us with important information that could help in designing a next generation EHR Graphical User Interface (GUI) that is more congruent with physicians' mental models, task performance needs, and workflow requirements.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.