Comparing Scribed and Non-scribed Outpatient Progress Notes.
Journal
AMIA ... Annual Symposium proceedings. AMIA Symposium
ISSN: 1942-597X
Titre abrégé: AMIA Annu Symp Proc
Pays: United States
ID NLM: 101209213
Informations de publication
Date de publication:
2021
2021
Historique:
entrez:
21
3
2022
pubmed:
22
3
2022
medline:
12
4
2022
Statut:
epublish
Résumé
Working with scribes can reduce provider documentation time, but few studies have examined how scribes affect clinical notes. In this retrospective cross-sectional study, we examine over 50,000 outpatient progress notes written with and without scribe assistance by 70 providers across 27 specialties in 2017-2018. We find scribed notes were consistently longer than those written without scribe assistance, with most additional text coming from note templates. Scribed notes were also more likely to contain certain templated lists, such as the patient's medications or past medical history. However, there was significant variation in how working with scribes affected a provider's mix of typed, templated, and copied note text, suggesting providers adapt their documentation workflows to varying degrees when working with scribes. These results suggest working with scribes may contribute to note bloat, but that providers' individual documentation workflows, including their note templates, may have a large impact on scribed note contents.
Types de publication
Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
1059-1068Subventions
Organisme : AHRQ HHS
ID : R01 HS025141
Pays : United States
Informations de copyright
©2018 AMIA - All rights reserved.
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