Clinical notes are notes prepared in conjunction with a physician-patient encounter and are very significant for primary care physicians (PCPs) to provide appropriate care for a specific patient. Transcribing clinical notes is an important part of family practice transcription, which provides a complete narrative of the patient encounter through several components such as chief complaint and history of present illness to assessment, plan of care, and follow-up information. The use of electronic health records or EHRs is supposed to improve the quality of clinical notes as the system can capture more details from the visit previously missed. However, a new study reveals that many physicians are not satisfied with their EHR performance and it is time to redesign EHR documentation to enhance clinical notes and provide quality care.
The study published in the Journal of the American Board of Family Medicine this May, focused on the cognitive load faced by primary care physicians daily as a result of electronic health record documentation. The researchers watched primary care physicians handling EHRs when preparing for patient visits, and requested them to highlight those parts of the clinic note they found most important and least important. For this study, the researchers used cognitive task analysis with 16 primary care physicians in the scenario of preparing for office visits. The physicians reviewed simulated acute and chronic care visit notes. The researchers collected field notes, document highlighting and review; they audio-recorded cognitive interview while on task, which was followed by thematic qualitative analysis. The findings were presented to the interviewed physicians and their faculty peers.
The results of the study provided a better view regarding how physicians reviewed each component of clinical notes (within EHR) and whether they were beneficial to them. The crucial findings among them are as follows:
- The Assessment and Plan section was typically reviewed first and it was considered the most important section.
- The History of the Present Illness section could provide supporting information to the physicians, particularly if it is in narrative form.
- Physicians were not that happy with the Review of System section and they complained that the section did not match their information needs.
- Certain information contained in other parts of the chart (for example, medication lists) was repetitive and identified as a source of clutter within clinical notes. A workflow that included a patient summary dashboard resulted in certain elements of past notes becoming redundant, and was also identified as a source of clutter.
The study concluded that current ambulatory progress notes provided more information to the PCPs than they actually needed. It is also important to reengineer the clinical progress notes to match the workflow as well as information needs of its primary consumer.
With this study, we can say that even though EHR templates and checklists are helpful for physicians, they may not ensure a complete clinical note. Primary care physicians should stop excessively relying upon pre-populated templates. They should also avoid using overly general templates for documenting patient encounters and select an EMR that is customized to their specific needs. It is also very important to verify whether the patient information accurately reflects the nature of the encounter before entering the data into the EHR. A combined approach of EHR and medical transcription can improve the quality of clinical notes and enable you to provide optimum care to your patients. This approach involves transcribing the physician recordings, verifying the transcribed data and populating them into corresponding EHR fields with the help of a transcription service provider.