ArticleApplied clinical informatics2016
Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record.
Article in Applied clinical informatics, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 11 papers.
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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
11 citing papers in PubMed.
- Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial.Journal of general internal medicine · 2021Trial
- Exploring Provider Perceptions and Attitudes toward Copy-Paste and Copy-Forward in Clinical Documentation.Applied clinical informatics · 2025Article
- Evaluating Hospital Course Summarization by an Electronic Health Record-Based Large Language Model.JAMA network open · 2025Article
- Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs.BMC primary care · 2024Observational
- Copy-Pasting in Patients' Electronic Medical Records (EMRs): Use Judiciously and With Caution.Cureus · 2023Review
- The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.Journal of medical systems · 2022Article
- Improving Medical Student Inpatient Documentation Through Feedback Using a Note Assessment Tool.Cureus · 2022Article
- Challenges and Opportunities to Improve the Clinician Experience Reviewing Electronic Progress Notes.Applied clinical informatics · 2019Article
- Electronic Health Record Documentation Patterns of Recorded Primary Care Visits Focused on Complex Communication: A Qualitative Study.Applied clinical informatics · 2019Article
- Open Notes in Teaching Clinics: A Multisite Survey of Residents to Identify Anticipated Attitudes and Guidance for Programs.Journal of graduate medical education · 2018Article
- Use of dictation as a tool to decrease documentation errors in electronic health records.Journal of community hospital internal medicine perspectives · 2017Article
Corrections and comments
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Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundCommunication errors are identified as a root cause contributing to a majority of sentinel events. The clinical note is a cornerstone of physician communication, yet there are few published interventions on teaching note writing in the electronic health record (EHR). This is a prospective, two-site, quality improvement project to assess and improve the quality of clinical documentation in the EHR using a validated assessment tool.
methodsInternal Medicine (IM) residents at the University of Kentucky College of Medicine (UK) and Montefiore Medical Center/Albert Einstein College of Medicine (MMC) received one of two interventions during an inpatient ward month: either a lecture, or a lecture and individual feedback on progress notes. A third group of residents in each program served as control. Notes were evaluated with the Physician Documentation Quality Instrument 9 (PDQI-9).
resultsDue to a significant difference in baseline PDQI-9 scores at MMC, the sites were not combined. Of 75 residents at the UK site, 22 were eligible, 20 (91%) enrolled, 76 notes in total were scored. Of 156 residents at MMC, 22 were eligible, 18 (82%) enrolled, 40 notes in total were scored. Note quality did not improve as measured by the PDQI-9.
conclusionThis educational quality improvement project did not improve the quality of clinical documentation as measured by the PDQI-9. This project underscores the difficulty in improving note quality. Further efforts should explore more effective educational tools to improve the quality of clinical documentation in the EHR.
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