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Cited by 26Electronic Health Records SystemsNursing Diagnosis and DocumentationHospital Admissions and Outcomes

Effect of outpatient note templates on note quality: NOTE (Notation Optimization through Template Engineering) randomized clinical trial

Open access
Epstein, Jeremy A., Cofrancesco, Joseph, Beach, Mary Catherine, Bertram, Amanda, Hedian, Helene F., Mixter, Sara, Yeh, Hsin-Chieh, Berkenblit, Gail·2021·Journal of General Internal Medicine
DOI 10.1007/s11606-020-06188-0PMC PMC7947083
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Abstract

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 encounter to evaluate note templates before the introduction into practice.Trial registration ClinicalTrials.gov ID: NCT04333238.

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  • In one study, experienced reviewers judged notes using a redesigned template to be less accurate and less useful than prior-state notes, despite resident perceptions of improved organization and visual appeal.

    “In one study, experienced reviewers judged notes using a redesigned template to be less accurate and less useful than prior-state notes, despite resident perceptions of improved organization and visual appeal (16).”

    From Cocreating the ICU-PAUSE Tool for Intensive Care Unit–Ward Transitions (2022) · cites this paper as [16]

    The Results (page not provided) report that faculty reviewers rated notes from the redesigned template less accurate and less useful than control notes, while residents rated them more visually appealing. The claim assigns improved organization to resident perceptions, but the Results attribute that rating to faculty reviewers; residents instead reported less redundancy and clutter. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The redesigned notes in that study were informed mainly via external resources rather than specific needs of users and other stakeholders.

    “Notably, these redesigned notes were informed mainly via external resources (research and a national organization position statement), rather than specific needs of users and other stakeholders.”

    From Cocreating the ICU-PAUSE Tool for Intensive Care Unit–Ward Transitions (2022) · cites this paper as [16]

    The Methods section (page unavailable) says the redesigned template drew on research and an American College of Physicians position statement. It also says a focus group of residents and attending physicians designed it using their collective experience. The paper does not establish that external resources were the main influence or that users’ specific needs were excluded. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

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Authors
Epstein, J. A., Cofrancesco, J., Beach, M. C., Bertram, A., Hedian, H. F., Mixter, S., Yeh, H.-C., & Berkenblit, G.
Affiliations
Johns Hopkins University (US)
Corresponding author
Epstein, Jeremy A.
ORCID
Venue
Journal of General Internal Medicine
Publisher
Springer Science and Business Media LLC
Published
2020-09-08
Volume
36
Issue
3
Pages
580-584
ISSN
  • 0884-8734 (ISSN-L)
  • 1525-1497
DOI
10.1007/s11606-020-06188-0
PMC
PMC7947083
OpenAlex
W3084321872
Cited by
26
References
27
Citations by year
2026: 6 · 2025: 5 · 2024: 4 · 2023: 6 · 2022: 2 · 2021: 3
FWCI
2.41
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of General Internal Medicine (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
Johns Hopkins University
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
  • Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
Keywords
note templates, note quality, simulated patient encounters, internal medicine residents, documentation efficiency
MeSH terms
Humans, Medical Records, Outpatients

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