Author(s): Kargul GJ, Wright SM, Knight AM, McNichol MT, Riggio JM
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Abstract Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation. Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5\% and 60\% to 100\% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3\% to 0\% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming electronic progress note.
This article was published in Am J Med Qual
and referenced in Journal of Health & Medical Informatics