The Impact of Diagnosis-Specific Plan Templates on Admission Note Writing Time: A Quality Improvement Initiative

There are limited objective studies regarding the effectiveness of strategies to alleviate the documentation burden on resident physicians. To develop and implement diagnosis-specific templates for the plan of care section of inpatient admission notes, aiming to reduce documentation time. Twelve tem...

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Veröffentlicht in:Journal of graduate medical education 2024-10, Vol.16 (5), p.581-587
Hauptverfasser: Rumlow, Zachary, Almodallal, Yahya, Zimmerman, M Bridget, Miner, Rebecca, Asbury, Rachel, Knake, Lindsey A, Schmitz, Anna
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Sprache:eng
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Zusammenfassung:There are limited objective studies regarding the effectiveness of strategies to alleviate the documentation burden on resident physicians. To develop and implement diagnosis-specific templates for the plan of care section of inpatient admission notes, aiming to reduce documentation time. Twelve templates for the plan of care section of admission notes were written by the study authors, reviewed by attending physicians, and shared with the residents through the electronic health record (EHR) on September 23, 2022. EHR audit log data were collected to examine admission note writing times, supplemented by resident feedback on acceptability via an anonymous survey. Feasibility measures included time investment, experience with the EHR, and resident training. Between July 1, 2021 and June 30, 2023, 62 pediatric residents contributed 9840 admission notes. The templates were used in 557 admission notes. The mean total time spent on an admission note decreased from 97.9 minutes pre-intervention to 71.0 minutes post-intervention with the use of a template; an adjusted reduction of 23% (95% CI 16%-30%;
ISSN:1949-8349
1949-8357
1949-8357
DOI:10.4300/JGME-D-24-00087.1