Journal article
Internal medicine progress note writing attitudes and practices in an electronic health record
Journal of hospital medicine, Vol.10(8), pp.525-529
08/2015
DOI: 10.1002/jhm.2379
PMID: 26138806
Abstract
The electronic health record (EHR) has been viewed with both praise and skepticism. Multiple editorials have expressed concerns that EHR implementation and "efficiency tools" such as copy forward and auto population have resulted in a decrement in note accuracy, relevance, and critical thinking.
To evaluate the perceptions of internal medicine housestaff and attendings on inpatient progress note quality at 4 academic institutions after the implementation of an EHR.
Cross-sectional survey.
We developed surveys that assessed housestaff and attendings opinion of current progress note quality, the impact of the EHR on quality, and the purposes of a progress note.
We received 99 completed surveys from interns (66%), 155 from residents (49%), and 153 from attendings (70%) across 4 institutions. The majority of housestaff responded that the quality of notes was "unchanged" or "better" following the implementation of an EHR, whereas attendings believed note quality was "unchanged" or "worse." Attendings' perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes across all domains. With regard to the effect of copy forward and autopopulation, the majority of housestaff viewed these to be "neutral" or "somewhat positive," whereas attendings viewed these as "neutral" or "somewhat negative." Housestaff and attendings had nearly perfect agreement regarding the purpose of the progress note.
Attendings and housestaff disagree on the current quality of progress notes and the impact of an EHR on note quality, but agree on the purpose of a progress note.
Details
- Title: Subtitle
- Internal medicine progress note writing attitudes and practices in an electronic health record
- Creators
- Elizabeth Stewart - Department of Medicine, Division of Hospital Medicine, Alameda Health System, Oakland, CaliforniaDaniel Kahn - Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CaliforniaEdward Lee - Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CaliforniaWendy Simon - Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CaliforniaMark Duncan - Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CaliforniaHilary Mosher - Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IowaKatherine Harris - Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IowaJohn Bell - Department of Internal Medicine, Division of Hospital Medicine, University of California, San Diego, San Diego, CaliforniaNeveen El-Farra - Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CaliforniaBradley Sharpe - Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
- Resource Type
- Journal article
- Publication Details
- Journal of hospital medicine, Vol.10(8), pp.525-529
- DOI
- 10.1002/jhm.2379
- PMID
- 26138806
- ISSN
- 1553-5592
- eISSN
- 1553-5606
- Language
- English
- Date published
- 08/2015
- Academic Unit
- General Internal Medicine; Internal Medicine
- Record Identifier
- 9984094535102771
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