Evolution and use of a note classification scheme in an electronic medical record

Abstract

Titles of clinical notes within an electronic medical record (EMR) are important because they influence the speed and completeness of the review of a patient's health record. We created a note classification scheme for notes in our EMR consisting of a 2 level hierarchy of note titles used to identify newly created and existing text and scanned notes. In a sample of 3 of the 18 months since beginning production use, an average of 2,810 notes are added each day. The number of distinct note titles rose by 32 percent between November 2003 and February 2005. Few changes were made to the upper level of the hierarchy. Thirty-three note titles accounted for 75% of the notes entered in February 2005. Note titles are one of several attributes that in conjunction with the user interface used to display them may affect the efficiency and completeness with which clinicians review their patient's records.

Figure 1. View of ORCA notes by type.

This is the Clinical Notes tab of Cerner Powerchart. Three mouse double-clicks lead to this view: first opens folder in top level of the note title hierarchy; second opens folder for 2^nd level of hierarchy, third opens selected note.

Figure 2. MINDscape Transcripts tab user interface.

A list of notes within the ORCA Millennium database is shown using a web browser, with 7 attributes for each note.