Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomize
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BACKGROUND: This is the first randomized controlled trial evaluating the impact of note template design on note quality using a simulated patient encounter and a validated assessment tool. OBJECTIVE: To compare note quality between two different templates using a novel randomized clinical simulation process. DESIGN: A randomized non-blinded controlled trial of a standard note template versus redesigned template. PARTICIPANTS: PGY 1-3 IM residents. INTERVENTIONS: Residents documented the simulated patient encounter using one of two templates. The standard template was modeled after the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment, and deemphasized less useful elements. MAIN MEASURES: Note length; time to note completion; note template evaluation by resident authors; note evaluation by faculty reviewers. KEY RESULTS: 36 residents participated, 19 randomized to standard template, 17 to new. New template generated shorter notes (103 vs 285 lines, p < 0.001) that took the same time to complete (19.8 vs 21.6 min, p = 0.654). Using a 5-point Likert scale, residents considered new notes to have increased visual appeal (4 vs 3, p = 0.05) and less redundancy and clutter (4 vs 3, p = 0.006). Overall template satisfaction was not statistically different. Faculty reviewers rated the standard note more up-to-date (4.3 vs 2.7, p = 0.001), accurate (3.9 vs 2.6, p = 0.003), and useful (4 vs 2.8, p = 0.002), but less organized (3.3 vs 4.5, p < 0.001). Total quality was not statistically different. CONCLUSIONS: Residents rated the new note template more visually appealing, shorter, and less cluttered. Faculty reviewers rated both note types equivalent in the overall quality but rated new notes inferior in terms of accuracy and usefulness though better organized. This study demonstrates a novel method of a simulated clinical
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-06188-0) contains supplementary material, which is available to authorized users. Received April 16, 2020 Accepted August 26, 2020
encounter to evaluate note templates before the introduction into practice. T R I A L R E G I ST R AT I O N : C l i n i c a l Tr i a l s . g o v I D : NCT04333238 KEY WORDS: Clinical documentation; Note quality; Note template. J Gen Intern Med DOI: 10.1007/s11606-020-06188-0 © Society of General Internal Medicine 2020
INTRODUCTION
Providers often decry the state of current notes with the trend towards copy-forwarding as well as the inclusion of excess automatically imported data.1,2 The current literature on note reform describes the introduction of new note templates, often paired with note-writing education. Thus far, studies have relied mainly on pre/post analyses, assessment using provider opinion, and non-validated survey instruments.3–8 The purpose of this study was twofold: first, to implement a novel process for note evaluation using rigorous methodology of a randomiz
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