Experience in implementing inpatient clinical note capture via a provider order entry system

Abstract

Care providers' adoption of computer-based health-related documentation ("note capture") tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note-capture tool that has been made available to end users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note-capture tool usage between January 1, 1999, and December 31, 2001, increased substantially, both in the number of users and in their frequency of use. This case report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer-assisted documentation tool-a concept that may seem counterintuitive to some.

Figure 1.

The notes editor interface with a template automatically modified into a note outline from four different data sources for a 22-year-old woman.

Figure 2.

The integration of the clinical note-capture tool (CNCT) with other institutional information systems. After launching the CNCT, the user selects either a template or a previous note draft from the template repository. The CNCT then modifies the template into a note outline that includes demographic information and age-/gender-specific content and content from the provider order entry system. The user then can augment the note by typing and by initiating unidirectional queries of the data repository for additional information, such as laboratory results and problem lists. Once completed, the note can be stored in the data repository and printed for inclusion in a paper chart.