Internal medicine progress note writing attitudes and practices in an electronic health record.
J Hosp Med. 2015 Jul 2;
Authors: Stewart E, Kahn D, Lee E, Simon W, Duncan M, Mosher H, Harris K, Bell J, El-Farra N, Sharpe B
Abstract
BACKGROUND: The electronic health record (EHR) has been viewed with both praise and skepticism. Multiple editorials have expressed concerns that EHR implementation and "efficiency tools" such as copy forward and auto population have resulted in a decrement in note accuracy, relevance, and critical thinking.
OBJECTIVE: To evaluate the perceptions of internal medicine housestaff and attendings on inpatient progress note quality at 4 academic institutions after the implementation of an EHR.
DESIGN: Cross-sectional survey.
MEASUREMENTS: We developed surveys that assessed housestaff and attendings opinion of current progress note quality, the impact of the EHR on quality, and the purposes of a progress note.
RESULTS: We received 99 completed surveys from interns (66%), 155 from residents (49%), and 153 from attendings (70%) across 4 institutions. The majority of housestaff responded that the quality of notes was "unchanged" or "better" following the implementation of an EHR, whereas attendings believed note quality was "unchanged" or "worse." Attendings' perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes across all domains. With regard to the effect of copy forward and autopopulation, the majority of housestaff viewed these to be "neutral" or "somewhat positive," whereas attendings viewed these as "neutral" or "somewhat negative." Housestaff and attendings had nearly perfect agreement regarding the purpose of the progress note.
CONCLUSIONS: Attendings and housestaff disagree on the current quality of progress notes and the impact of an EHR on note quality, but agree on the purpose of a progress note. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.
PMID: 26138806 [PubMed - as supplied by publisher]