Study shows doctors record better notes after using best-practices program

FINDINGSThe quality and efficiency of notes doctors took about their patients improved when they received education and guidelines that emphasized best practices. In a study led by UCLA researchers, physicians were instructed to document only what was relevant for that day and were discouraged from using some common tools that are intended to make note-taking more efficient. During the study period, physicians produced shorter, higher quality notes and completed the notes earlier in the day. By limiting the efficiency tools, note writing actually became more efficient.BACKGROUNDThe widespread adoption of electronic health records is helping to modernize health care delivery. However, the growth of electronic health records posed some challenges for accurate and concise documentation of physician notes. Experts have described several problems that are occurring in physician notes.  One is inaccurate information that leads to errors. Another is inconsistent or outdated information that doesn’t get corrected in the patient’s record — a practice referred to as “copying-forward.” While another is the phenomenon of “note bloat” in which physician notes are overly lo ng and contain nonessential information. The UCLA researchers explored whether an education program used in combination with a template used to guide doctors through the note-taking process can improve the quality, length and timeliness of physician notes.METHODThe quality improvement study, led by Dr. Ne...

Source: UCLA Newsroom: Health Sciences - January 17, 2018 Category: Universities & Medical Training Source Type: news