Problem Specific Templates for Electronic Hospital Documentation
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 10
- 试验地点
- 1
- 主要终点
- Quality and Accuracy of Physician Documentation Practices (as measured through chart review)
研究概览
简要总结
The emergence of electronic documentation has led to multiple new challenges for physicians. Despite positive expectations, many physicians have received electronic health systems with mixed results. Review of current literature has identified the following reasons for concern: increased time required for documentation, deteriorating quality of notes, mindless use of copy-and-paste functions, and fragmentation of clinical work from poorly designed computing workflows. The study of template use has not been done in a large scale or with clear outcome measurements. The purpose of this study is to examine the effects of Problem Specific Templates on quality, accuracy, and efficiency of physician documentation practices.
详细描述
This is a prospective cohort study, which will examine the effects of Problem Specific Templates on quality, accuracy, and efficiency of physician documentation practices. The Hospitalist physicians will be the subjects. All physicians of the Hospital Medicine Service will be invited to participate. For the intervention, participating Hospitalists will be trained on the use of templates for 20 common hospital problems. Once trained, the Hospitalists will be asked to use these templates for a one-month period. Pre-intervention and post-intervention medical records will be compared using chart reviews, validated document assessment instruments, physician surveys, and electronic medical record time auditing.
研究设计
- 研究类型
- Observational
- 观察模型
- Cohort
- 时间视角
- Prospective
入排标准
- 年龄范围
- 18 Years 至 70 Years(Adult, Older Adult)
- 性别
- All
- 接受健康志愿者
- 是
入选标准
- •Physicians: All physicians of the Hospital Medicine Service will be invited to participate
排除标准
- •Any invited physicians who refuse to consent
结局指标
主要结局
Quality and Accuracy of Physician Documentation Practices (as measured through chart review)
时间窗: 1 year
Efficiency of Physician Documentation Practices (as measured through the electronic medical record auditing function)
时间窗: 1 year
次要结局
- Physician Assessment of Note-Documenting and Electronic Medical Record (as measured through Physician Questionnaire)(1 year)
- Frequency of Physician Use of Problem Specific Templates (as measured through chart review)(1 year)
