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M.e.a.t. clinical documentation1/9/2024 ![]() ![]() Clinical notes play an important role in the so called EHR-associated documentation burden as they contribute to information overload 11. The latter is particularly challenging because the clinical documentation that is essential in facilitating memory and recall and to enable understanding and care coordination 9, has become an increasing source of frustration among clinicians 10. ![]() Some notorious limitations of current systems include confusing interfaces 6, excessive, overzealous alerts and reminders 7, and bloated clinical notes 8. As a result, new unintended consequences have emerged at different levels of the U.S. These systems were adopted before facing a thorough redesign 3 and before accumulation of compelling evidence of their full impact 4. health system has reached unprecedented electronic health record (EHR) adoption 1, which was achieved through large-scale adoption of commercial EHRs 2. Primarily driven by financial incentives provided by the Meaning Use program, the U.S. We identified commonly used narrative note section formats and developed a taxonomy of narrative note content to help researchers to tailor their efforts and design more efficient clinical documentation systems. We identified seven taxa representing 45 different types of data: finding/condition documented (n = 14), intervention documented (n = 9), general descriptions and definitions (n = 7), temporal information (n = 6), reasons and justifications (n = 4), participants and settings (n = 4), and clinical documentation (n = 1).Ĭonclusion. HPI and IP content was significantly smaller in combination C compared to combination A (-172 words, p = 0.02). We identified five combinations of format of HPI + IP sections respectively: (A) story + list with categories (B) story + story (C) list without categories + list with categories (D) list with categories + list with categories and (E) list with categories + story. Although we did not find a significant difference in the overall note size between the two groups, the proportion of HPI and IP content in relation to the total note size was significantly higher in primary care notes (40%, SD vs. Both HPI and IP were significantly longer in primary care when compared to specialty care notes (HPI: n = 187 words, SD vs. We then annotated the content of these sections to develop a taxonomy of types of data communicated in the narrative note sections. Two authors iteratively classified the format of the sections and compared the size of each section and the overall note size between primary and specialty care notes. We extracted data from the history of present illness (HPI) and impression and plan (IP) sections of 80 primary and specialty care visit notes. We systematically analyzed the most commonly used narrative note formats and content found in primary and specialty care visit notes to inform future research and electronic health record (EHR) development. ![]()
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