Notation Optimization Through Template Engineering
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 36
- 试验地点
- 2
- 主要终点
- Note evaluation by authors using a likert scale
研究概览
简要总结
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.
详细描述
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.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Other
- 盲法
- None
入排标准
- 性别
- All
- 接受健康志愿者
- 是
入选标准
- •Residents who had open visit slots during their outpatient clinic time
排除标准
- 未提供
结局指标
主要结局
Note evaluation by authors using a likert scale
时间窗: Immediately after note entry, up to 1 hour
Likert-scale survey instrument evaluating perceived organization, structure, and efficiency of note.
Note length
时间窗: Duration of note entry, up to 2 hours
Note length in line count.
Time to note completion
时间窗: Duration of note entry, up to 2 hours
Time to note completion in minutes.
Note evaluation by reviewers using the Physician Documentation Quality Instrument
时间窗: 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.
次要结局
未报告次要终点