Notation Optimization Through Template Engineering

Not Applicable

Completed

• Conditions: Clinical Documentation
• Interventions: Other: New progress note template; Other: Standard progress note template

• Registration Number: NCT04333238
• Lead Sponsor: Johns Hopkins University

Brief Summary

This is a randomized non-blinded controlled trial of a standard note template versus a redesigned note template using a simulated patient encounter and the electronic medical record.

Detailed Description

Residents documented the simulated patient encounter using one of two templates. The standard template was based on the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment section, and deemphasized elements not related to the current presentation.

Study Timeline

• Study Start: 2017-01-20
• Primary Completion: 2017-04-26
• Study Completion: 2018-12-01
• Study First Submitted: 2020-03-29
• Status Verified: 2020-04
• Study First Submitted QC: 2020-04-02
• Study First Posted: 2020-04-03
• Last Update Submitted: 2023-03-15
• Last Update Posted: 2023-03-17

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 36

Inclusion Criteria

• Residents who had open visit slots during their outpatient clinic time

Exclusion Criteria

• None

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
New template	New progress note template	The assessment and plan section is placed in the beginning, subjective data grouped into the assessment section, and elements not related to the current presentation were deemphasized
Standard template	Standard progress note template	Usual outpatient progress note with standard Subjective Objective Assessment Plan (SOAP) format

Primary Outcome Measures

Name	Time	Method
Note evaluation by authors using a likert scale	Immediately after note entry, up to 1 hour	Likert-scale survey instrument evaluating perceived organization, structure, and efficiency of note.
Note length	Duration of note entry, up to 2 hours	Note length in line count.
Time to note completion	Duration of note entry, up to 2 hours	Time to note completion in minutes.
Note evaluation by reviewers using the Physician Documentation Quality Instrument	Within 1 year	Physician Documentation Quality Instrument (PDQI-9) - validated note quality scale composed of 9 metrics. 1 is not at all. 5 is extremely.

Trial Locations

Locations (1)

Johns Hopkins Outpatient Center; 🇺🇸 Baltimore, Maryland, United States