Trial reportJournal of the American Medical Informatics Association : JAMIA2017
An electronic documentation system improves the quality of admission notes: a randomized trial.
Trial report in Journal of the American Medical Informatics Association : JAMIA, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 16 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
16 citing papers in PubMed, 1 synthesis or guideline pooled it.
- The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals-A Systematic Review.Journal of medical systems · 2022Pooled it
- Pre-diagnosis and pre-treatment loss to follow-up and associated factors among patients with presumed tuberculosis and those diagnosed in Uganda.BMC health services research · 2024Article
- Article
- Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health System.Applied clinical informatics · 2024Article
- An evaluation of staff experiences of the Royal Literary Fund writer-in-residence service to support improvements in written communication in healthcare.Qualitative research in medicine & healthcare · 2023Article
- Medical Note Quality Audit at the Vascular Surgical Unit Compared With the British Medical Journal (BMJ) Guidelines.Cureus · 2023Article
- A cross-sectional retrospective study comparing handwritten operation notes with electronic operation notes.Annals of the Royal College of Surgeons of England · 2023Article
- Computer System for the Capture and Preparation of Cytopathological Reports for Cervical Cancer Detection and His Utility in Training for Health Personnel.European journal of investigation in health, psychology and education · 2022Article
- The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.Journal of medical systems · 2022Article
- Identification of data elements for blood gas analysis dataset: a base for developing registries and artificial intelligence-based systems.BMC health services research · 2022Review
- Evaluating Simplified Web Interfaces of Risk Models for Clinical Use: Pilot Survey Study.JMIR formative research · 2021Article
- A Practical Approach for Monitoring the Use of Copy-Paste in Clinical Notes.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2021Article
- Aspects of Technology That Influence Athletic Trainers' Current Patient Care Documentation Strategies in the Secondary School.Journal of athletic training · 2020Article
- Linking Quality Improvement and Health Information Technology through the QI-HIT Figure 8.Applied clinical informatics · 2019Article
- The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine.Applied clinical informatics · 2017Article
- Clinical Information Systems as the Backbone of a Complex Information Logistics Process: Findings from the Clinical Information Systems Perspective for 2016.Yearbook of medical informatics · 2017Review
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveThere are concerns that structured electronic documentation systems can limit expressivity and encourage long and unreadable notes. We assessed the impact of an electronic clinical documentation system on the quality of admission notes for patients admitted to a general medical unit.
methodsThis was a prospective randomized crossover study comparing handwritten paper notes to electronic notes on different patients by the same author, generated using a semistructured electronic admission documentation system over a 2-month period in 2014. The setting was a 4-team, 80-bed general internal medicine clinical teaching unit at a large urban academic hospital. The quality of clinical documentation was assessed using the QNOTE instrument (best possible score = 100), and word counts were assessed for free-text sections of notes.
resultsTwenty-one electronic-paper note pairs (42 notes) written by 21 authors were randomly drawn from a pool of 303 eligible notes. Overall note quality was significantly higher in electronic vs paper notes (mean 90 vs 69, P < .0001). The quality of free-text subsections (History of Present Illness and Impression and Plan) was significantly higher in the electronic vs paper notes (mean 93 vs 78, P < .0001; and 89 vs 77, P = .001, respectively). The History of Present Illness subsection was significantly longer in electronic vs paper notes (mean 172.4 vs 92.4 words, P = .0001).
conclusionsAn electronic admission documentation system improved both the quality of free-text content and the overall quality of admission notes. Authors wrote more in the free-text sections of electronic documents as compared to paper versions.
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