Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Dec 5:2018:1310-1318.
eCollection 2018.

Clinical Documentation in Electronic Health Record Systems: Analysis of Similarity in Progress Notes from Consecutive Outpatient Ophthalmology Encounters

Abigail E Huang  1   2 , Michelle R Hribar  2 , Isaac H Goldstein  3 , Brad Henriksen  3 , Wei-Chun Lin  2 , Michael F Chiang  2   3
Affiliations

Clinical Documentation in Electronic Health Record Systems: Analysis of Similarity in Progress Notes from Consecutive Outpatient Ophthalmology Encounters

Abigail E Huang et al. AMIA Annu Symp Proc. .

Abstract

Content importing technology enables duplication of large amounts of clinical text in electronic health record (EHR) progress notes. It can be difficult to find key sections such as Assessment and Plan in the resulting note. To quantify the extent of text length and duplication, we analyzed average ophthalmology note length and calculated novelty of each major note section (Subjective, Objective, Assessment, Plan, Other). We performed a retrospective chart review of consecutive note pairs and found that the average encounter note was 1182 ± 374 words long and less than a quarter of words changed between visits. The Plan note section had the highest percentage of change, and both the Assessment and Plan sections comprised a small fraction of the full note. Analysis of progress notes by section and unique content helps describe physician documentation activity and inform best practices and EHR design recommendations.

PubMed Disclaimer

Figures

Figure 1.
Figure 1.
A) Box plot of mean total and new words per note section: Subjective-S, Objective-O, Assessment-A, Plan-P and Other. B) Box plot of mean total and new words for the overall note: SOAP words only and full encounter note.
Figure 2.
Figure 2.
Mean %new words +/- SD. %new words for individual note sections as well as for combined SOAP sections and overall note.
Figure 3.
Figure 3.
Mean %new words +/- SD in the full note. Analysis was done for each individual provider and for all providers combined.
See this image and copyright information in PMC

References

    1. Chan P, Thyparampil PJ, Chiang MF. Accuracy and speed of electronic health record versus paper-based ophthalmic documentation strategies. Am J Ophthalmol. 2013 Jul;156(1):165–172 e2. - PMC - PubMed
    1. Bae J, Encinosa WE. National estimates of the impact of electronic health records on the workload of primary care physicians. BMC Health Serv Res. 2016;10(16):172. - PMC - PubMed
    1. Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan W-J, Sinsky CA, et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med. 2017 Sep;15(5):419–26. - PMC - PubMed
    1. Chiang MF, Read-Brown S, Tu DC, Choi D, Sanders DS, Hwang TS, et al. Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013 Sep;111:70–92. - PMC - PubMed
    1. Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. Chest. 2014 Mar 1;145(3):632–8. - PubMed

LinkOut - more resources