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Recent changes to billing policy have reduced documentation requirements for outpatient notes, providing an opportunity to rethink documentation workflows. While many providers use templates to write notes—whether to insert short phrases or draft entire notes—we know surprisingly little about how these templates are used in practice. In this retrospective cross-sectional study, we observed the templates that primary providers and other members of the care team used to write the provider progress note for 2.5 million outpatient visits across 52 specialties at an academic health center between 2018 and 2020. Templates were used to document 89% of visits, with a median of 2 used per visit. Only 17% of the 100 230 unique templates were ever used by more than one person and most providers had their own full-note templates. These findings suggest template use is frequent but fragmented, complicating template revision and maintenance. Reframing template use as a form of computer programming suggests ways to maintain the benefits of personalization while leveraging standardization to reduce documentation burden.

The study aimed to identify the relationship between the role of head nurse and critical thinking of nurse to the documentation of integrated patient progress note. The study used a descriptive correlation design, a cross sectional approach, with a sample of 69 nurses who documented integrated patient pogress note, using cluster sampling techniques, through Pearson, Spearman, Mann Whitney and Linear Regression analyzes. There was a significant relationship between the role of head nurse (p=0.038; α=0.05) and the nurse's critical thinking (p=0.003; α=0.05) to the documentation of integrated patient progress note. Critical thinking of nurses is the most influential factor in documenting integrated patient progress note. Here needs to be a policy, evaluation and monitoring of the nursing manager through self-development in the application the role of head nurse, critical thinking of nurse and the implementation of documentation of integrated patient progress note

Background System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP. Aim To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE. Methods For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey. Results Survey response rate was 100%. The average composite score across SBP milestones for all cases were 6.22 (SBP1), 4.34 (SBP2), 3.35 (SBP3), and 6.42 (SBP4) out of 9. The lowest composite score was in SBP 3, which asks fellows to advocate for cost effective care. This highest score was in patient care 2, which asks fellows to develop comprehensive management plans. Discrepancies were identified between the fellows' perceived performance in their self-assessments and Standardized Patient checklist evaluations for each case. Eighty-seven percent of fellows agreed that OSCEs are an important component of their clinical training, and 83% stated that the cases were similar to actual clinical encounters. All participating fellows stated that the immediate feedback was "very useful." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice. Conclusion OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

Introduction Hospitals in Indonesia are obligated to implement Integrated Patient Progress Notes (IPPNs), also known as the "Catatan Perkembangan Pasien Terintegrasi". A progress note contains the entire interaction between patients and health professionals, including physicians, nurses, pharmacists, dietitians, and physiotherapists. However, since the first launch in 2012, obstacles and problems in completing this integrated documentation remains nationwide. Aim The objective of this investigation was to identify health professional's perspectives on obstacles and problems using IPPNs and facilitators that may optimize their use. Methods Five focus group discussions (FGDs) involving 37 participants took place. All FGDs were recorded, translated, and transcribed verbatim. A thematic analysis was used to interpret the data. Results The thematic analysis of the material revealed three main categories for each of the two topics; Topic 1. Perceived problems hindering integrated documentation: lack of supervision, competence, workload; topic 2: perceived strategies to optimize integrated documentation: organizational support, joint practices, integrating technology with IPPN. Conclusion The results indicate that health professionals see the importance of using IPPNs but only if implemented with educational and organizational support and that the use of an electronic patient record may be more effective than a paper record. To continue the implementation of IPPNs, it is suggested that it is preceded by educational and organizational support.

Background We developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers. Methods To build our SCDS toolkit, physicians met frequently to develop content, define the cohort, select outcome measures, and delineate factors known to modify disease progression. We assigned tasks to the care team and mapped data elements to the progress note. Programmer analysts built and tested the SCDS toolkit, which included several score tests. Auto scored and interpreted tests included the Generalized Anxiety Disorder 7-item, Center for Epidemiological Studies Depression Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia Severity Index, and the International Restless Legs Syndrome Study Group Rating Scale. The SCDS toolkits also provided clinical decision support (untreated anxiety or depression) and prompted enrollment of patients in a DNA biobank. Results The structured clinical documentation toolkit captures hundreds of fields of discrete data at each office visit. This data can be displayed in tables or graphical form. Best practice advisories within the toolkit alert physicians when a quality improvement opportunity exists. As of May 1, 2019, we have used the toolkit to evaluate 18,105 sleep patients at initial visit. We are also collecting longitudinal data on patients who return for annual visits using the standardized toolkits. We provide a description of our development process and screenshots of our toolkits. Conclusions The electronic medical record can be structured to standardize Sleep Medicine office visits, capture data, and support multicenter quality improvement and practice-based research initiatives for sleep patients at the point of care.

La détection d'insatisfaction basée sur les notes de progression rédigées par des soignants de la santé domestique attire de plus en plus d'attention en tant que méthode de sondage, ce qui aidera à réduire le taux de rotation du personnel soignant. Nous proposons d'étudier la détection d'insatisfaction du soignant comme un problème de classification binaire (le soignant est susceptible de quitter ou pas). Dans ce mémoire, les données réelles de six mois recueillies à partir de deux agences de soins à domicile sont utilisées. Après avoir montré la nature des données et le prétraitement des données, trois tâches de classification avec des granularités d'échantillonnage différentes (par note, par période et par soignant) sont conçues et abordées. Différentes combinaisons d'hyper-paramètres d'étiquetage sont soigneusement testées. Différentes méthodes de découpage sont couvertes pour montrer les limites des performances théoriques des modèles. L'aire sous la courbe ROC est utilisée pour évaluer les limites des approches mises en place que nous aurons mis en place. Les 6 ensembles d'attributs textuels et statistiques sont comparées. Enfin, les caractéristiques importantes des résultats sont analysées manuellement et automatiquement. Nous montrons que les modèles fonctionnent mieux "par note" et "par période" que "par soignant" en termes de classification des notes. L'analyse manuelle montre que les modèles capturent les facteurs d'insatisfaction bien qu'il y en ait assez peu. L'analyse automatique n'exprime cependant aucune information utile., Dissatisfaction detection based on the home health caregiver's progress note draws more and more attention as a probing method, which will help lower down the turnover rate. We propose to study the detection of dissatisfaction of health caregiver as a binary classification problem (the caregiver is likely to "leave" or "stay"). In this master thesis, the real six-month data collected from two home care agencies are used. After showing the nature of the data and the prepossessing of data, three classification tasks with different sample granularity (note wise, period wise and employee wise) are designed and tackled. Different combinations of labeling hyper-parameters are tested thoroughly. Different split methods are covered to show the theoretical performance boundaries of the models. The under the ROC curve area (AUC) scores are reported to show the description ability of each model. The 6 sets of textual and statistical features' performance are compared. Lastly, the important features from the results are analyzed manually and automatically. We show that models work better on note wise and period wise than employee wise in terms of classifying the notes. The result of manual analysis shows the models capture the dissatisfaction factors, although there are quite few. The result of automatic analysis doesn't show any useful information.

Background MedicineInsight is a database containing de-identified electronic health records (EHRs) from over 700 Australian general practices. To support the trust placed in analyses of MedicineInsight data, additional evidence regarding the accuracy of the data is needed. Methods This study measures the validity of algorithms available in MedicineInsight that identify patients with depression, anxiety, asthma, type 2 diabetes and osteoporosis. Fifty practices met eligibility criteria regarding patient load and location, five were randomly selected and four agreed to participate. Within each practice, 250 patients aged ≥ 40 years were randomly selected. This age restriction increased the prevalence of the evaluated conditions, thereby optimising statistical power. Trained staff review the full EHR for these patients, including progress notes and correspondence, which are not available in MedicineInsight because they may contain identifiable information. Results With data collection almost complete, the target sample size will not be attainable. Power calculations indicate the current sample of 479 should provide adequate precision. For each condition of interest, the sensitivity, specificity, positive predictive value and negative predictive value of the algorithm is calculated. The full EHR review is the gold standard against which the algorithms are benchmarked. Conclusions The findings will indicate whether these algorithms demonstrate adequate accuracy to be used for research and decision-making. Key messages This additional understanding regarding the accuracy of MedicineInsight data will facilitate the interpretation of analyses of MedicineInsight data and guide improvements to the algorithms.

Objective This study aimed to identify the effect of role empowerment of head nurse by Orlando theory approach on the implementation of progress note documentation. Method This study used pilot study approach in which the research process started from developing module of role empowerment of head nurse, implementing of role empowerment of head nurse on in patient ward and then followed by evaluating head nurse competencies through the use of observation sheet and patient progress note. Pre-experiment design with one group pretest–posttest without control was used to evaluate the effectiveness of the intervention, and 115 progress notes were selected through cluster sampling technique which then analyzed by Wilcoxon, Spearman and Kruskal–Wallis test. Results There was a significant quality improvement of the implementation of progress note recording following the intervention of head nurses’ role empowerment by Orlando theory approach (p = 0.0001; α = 0.025). Conclusions Nurse Staff competencies in documenting progress note were improved significantly through the role empowerment of head nurse by Orlando theory approach. Development of policy, supervision, evaluation, and monitoring by nurse manager are necessary, as well as organizing a workshop on the application of head nurse's role as manager and implementation of progress note documentation.

Background Therapeutic staff-patient interaction is fundamental in psychiatric care. It is recognized as a key to healing in and of itself, or a premise to enhance psychiatric treatment adherence. Still, little is known about how these interactions are recorded in nursing documentation. The purpose of the study was to assess the quality and quantity of staff-patient interactions as recorded in progress notes in nursing documentation. Methods The study has an observational registry study design. A random sample of 3858 excerpts was selected from progress notes in 90 patient journals on an acute psychiatric unit and an open inpatient district psychiatric centre (DPC) in Norway. The Scale for the Evaluation of Staff-Patient Interactions in progress notes (SESPI) was used to assess the progress note excerpts. It is developed to assess the quality and quantity in excerpt descriptions of staff-patient interactions in terms of empathic attunement. Descriptive statistics were calculated for the total sample and for each ward separately. Ordinal and multinomial logistic regression were used to estimate control for shift type, staff education level, and type of hospital ward. Results Only 7.6% of the total number of excerpts (N = 3858) described staff-patient interactions sufficiently to analyze them in terms of attunement. Compared to the DPC, the acute ward reported more staff-patient interactions. The evening excerpts reported more successful types of attunement than those from the night shifts. Education level did not contribute significantly to our models. Conclusion These findings present a unique insight into the quality and quantity of mental health nursing documentation regarding staff-patient interactions. Therapeutic interactions where staff tried to attune to the patients were rarely described. However, this is the first study measuring nursing documentation with the SESPI, and more studies are required to validate the scale and our findings. One potential clinical implication of this research is the development of a scale that personnel in psychiatric wards can have for evaluation of the quality of their reporting practice with emphasis on staff-patient interactions. By regular use this may help keeping up emphasis on emphatic attunement in milieu treatment contexts. Electronic supplementary material The online version of this article (10.1186/s12888-019-2236-y) contains supplementary material, which is available to authorized users.

n the not too distant past, illegible handwriting was considered to be the biggest problem with medical record keeping. Now the primary problem with medical records is that they are disorganized, and usually undigested, data dumps. A solution to at least part of this problem lies in utilizing the principles of the problem-oriented record. When one contemplates the optimal format for progress notes, it is worth considering the purposes of progress notes. While progress notes do, of course, play a role in billing, the primary purposes of a progress note should be to provide efficient and effective communication with all who are caring for that patient and to facilitate efficient and effective contemplation of the condition of and the plans for that patient. Although it is beyond the scope of this treatise on creating progress notes, it is also worth pointing out that all patient care notes will also occasionally have legal implications and lawyers reading clinical notes will pay far more attention to assessments and plans than they will to data and results recorded in progress notes that are always easily available elsewhere in the patient record. In other words, lawyers reviewing medical records want to know what the clinicians caring for a patient were thinking, in addition to what those clinicians actually did for that patient. While all of these issues must be kept in mind, we will focus primarily on the role of clinical notes in providing optimal patient care, particularly in the realm of cardiothoracic surgery, though the principles to be enunciated can apply to most disciplines and to most clinical environments.

Background Play specialists work closely with doctors and nurses to improve outcomes and the hospital experience for young patients. Documentation is an important but challenging aspect of their work. It should be incorporated into their workflow through a user-friendly format to minimise workload and record information that is useful to the multidisciplinary team (MDT) at the same time. Aim To develop a play specialist progress note format and to evaluate its capacity to generate useful information for the MDT. Method A questionnaire and inductive coding were used to develop a format incorporating the advantages of a structure focused on capturing useful information and the narrative style of documentation. The format, Well-being, Interests, Strategies, Evaluation (WISE), was aligned with play specialists' workflow and allowed for documentation of play in children's hospital care. Post-implementation evaluation comprised a usefulness survey and qualitative analyses of documentation. Results Perception of the usefulness of the WISE format was positive with nurses giving higher ratings than doctors. Gaps were identified for further investigation and improvement. Conclusion Play specialists could either adapt the WISE format or adopt a similar process in developing and evaluating documentation suitable for their own work environment.

Objective To evaluate the prevalence of delayed traumatic brain injury (TBI) diagnosis and cause of injury that resulted in a TBI diagnosis after military deployment. Design Medical record notes were reviewed in 2016 from a random sample of 1150 US military service members who had their first-time deployment in 2011 and likely sustained a TBI. Location and cause of the injury were extracted from the progress note for analysis. Participants and setting Active-duty US military service members who received an International Classification of Diseases, Ninth Revision code for a TBI diagnosis in a military facility. Main outcome measures Presence of TBI, location of injury, cause of injury, and time of diagnosis with respect to deployment. Results The odds of being diagnosed with a deployment-related TBI were 8 times higher during the first 4 weeks upon return from deployment than the subsequent 32 weeks. The likelihood of diagnosing a deployment-sustained TBI during weeks 5 to 32 was 2 times higher than during 33 to 76 weeks following return from deployment. The proportion of deployment-related TBI diagnoses decreased with time following return from deployment but remained above 40% during weeks 33 to 76. Service branch, gender, race, occupation, and time between TBI diagnosis and return from deployment were significant predictors of deployment-related TBIs. Moving motor vehicle, sports, parachute, and being struck by objects were the top causes of injury in garrison (nondeployed setting), whereas blast produced the majority (66%) of all causes of injuries that resulted in a TBI in the deployed setting. Conclusion The increased incidence rate of a TBI diagnosis following deployment can be attributed to delayed diagnosis of TBI sustained from injuries during deployment. TBIs sustained during deployment can be diagnosed beyond the initial 4 weeks after return from deployment and may continue up to 76 weeks following return from deployment.

The Housing First approach has shown promise in helping to combat homelessness among chronically homeless single males, but less is known about the approach when it is applied to families and young adults. This study examined data from a pilot Housing First program that served 78 families (n = 63) and single young adults (n = 15) with homeless histories and mental health and/or substance use disorders to explore program functioning and client service use patterns. Using an exploratory sequential mixed methods research design ( Creswell & Plano Clark, 2011 ), qualitative interview data were conducted first, and quantitative administrative data and qualitative progress note data were then analyzed to explore ideas presented in the qualitative interviews. The in-depth qualitative interviews with staff (N = 9) collected information on program functioning and client successes and challenges. Quantitative data were collected on all 78 clients and sources included administrative data about return to homelessness, child welfare involvement, receipt of public assistance, and interactions with case managers. Qualitative exploration of a sample of client progress notes (N = 32) then followed. Integrating the findings, interviews suggested that clients faced many challenges, especially those related to having little to no income, multiple children, and stigmas, but that “success” would be indicated by needing their case managers less over time. We found that 89% remained enrolled in the program, 21% returned to shelter at some point, child welfare involvement decreased, and public assistance receipt increased after program entry. Content analysis of case management notes indicated that case managers worked with clients to develop independent living skills to improve clients' chances for becoming sufficient over the long-term.

OBJECTIVES:Physicians increasingly share ambulatory visit notes with patients to meet new federal requirements, and evidence suggests patient experiences improve without overburdening physicians. Whether sharing inpatient notes with parents of hospitalized children yields similar outcomes is unknown. In this pilot study, we evaluated parent and physician perceptions of sharing notes with parents during hospitalization.METHODS:Parents of children aged RESULTS:In all, 25 parents and their children’s discharging attending and intern physicians participated. Parents agreed that the information in notes was useful and helped them remember their child’s care plan (100%), prepare for rounds (96%), and feel in control (91%). Although many physicians (34%) expressed concern that notes would confuse parents, no parent reported that notes were confusing. Some physicians perceived that they spent more time writing and/or editing notes (28%) or that their job was more difficult (15%). Satisfaction with sharing was highest among parents (100%), followed by attendings (81%) and interns (35%).CONCLUSIONS:Parents all valued having access to physicians’ notes during their child’s hospital stay; however, some physicians remained concerned about the potential negative consequences of sharing. Comparative effectiveness studies are needed to evaluate the effect of note sharing on outcomes for hospitalized children, families, and staff.