Structured Documentation of Patient Notes Promotes Higher Quality Care
According to a study conducted and published by the Journal of the American Medical Informatics Association, doctors who use structured patient documentation to record patient information provide higher quality care. Doctors who only dictate patient notes reported making more errors when entering information into Electronic Health Records (EHRs), as opposed to doctors who use structured documentation, a format that uses templates to divide patient visit notes into separate sections.
Researchers examined 188,554 patient visit notes written by physicians for all of their patients in Eastern Massachusetts. Data shows that 62 percent of physicians used free-text notes on paper or a Word document, 29 percent used proper patient documentation, and 9 percent dictated their notes. Dictation involves relaying the information to a third party and using it at a later time for documentation.
Researchers applied these three note-taking practices to several medical categories to analyze the effects they have on quality care. Some of these included:
- Tobacco use
- Antiplatelet medication
- Diabetes eye exam
- Blood pressure documentation
The study found that tobacco use was documented in the EHRs of 22 percent of patients who visited a doctor using dictation, 36 percent who visited a doctor using free-text notes, and 38 percent whose doctor used structured documentation. For medical measures such as blood pressure documentation, body mass index documentation and diabetic foot exam, structured documentation proved more accurate than the other two forms of patient notes.
According to this study, higher quality care results from doctors recording patient information and health history using structured documentation. In one instance, the researchers found that doctors who use free-text notes are most effective in prescribing influenza vaccines; dictation did not result in higher quality care in any of the medical categories measured.
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