Trial reportJournal of general internal medicine2025
Smarter Documentation: Measuring and Improving the Quality of Progress Notes Written by Hospitalists.
Trial report in Journal of general internal medicine, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundProgress notes written about hospitalized patients are suboptimal. Notes are bloated and awash with inaccuracies. Poor notes negatively impact patient care.
objectiveTo design and assess a progress note scoring rubric and educational intervention aimed at improving the quality of progress notes.
designRandomized control educational trial.
participantsHospitalist physicians at a large academic medical center.
interventionHospitalists were randomized to either a multi-pronged educational intervention or the control group.
main outcome measureA scoring rubric was developed to measure the quality of progress notes; validity evidence was established for the measure. This rubric was used by assessors (blinded to both group and pre/post periods) to evaluate progress notes. Notes were pulled from 6 months before and after the intervention period (n = 156 notes). KEY
resultsOf the 26 participating hospitalists, 14 were randomized to the intervention. The two groups of hospitalists were similar in terms of age, gender, and clinical experience (all p > 0.05). Both groups had comparable notes at baseline (total score, 0.32 vs. 0.30, p = 0.59). After participating in the educational session, all 14 of the rubric items were higher in the intervention group-both compared to the control group and to their baseline/PRE notes-many changes reaching statistical significance. Total scores for the intervention group improved significantly (all p < 0.05). The instruments' total score and global rating of "how well the note would prepare the next provider to take over the care of the patient" were highly correlated-0.72. Note length was not extended by the intervention (p > 0.05).
conclusionsThis work established both an objective scoring rubric to assess the quality of progress notes and an efficient, impactful method for coaching hospitalists. For other groups striving to improve progress note quality, this study provides a blueprint for how they might proceed.
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