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This is a randomized non-blinded controlled trial of a standard note template versus a redesigned note template using a simulated patient encounter and the electronic medical record.
Residents documented the simulated patient encounter using one of two templates. The standard template was based on the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment section, and deemphasized elements not related to the current presentation.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Standard template | Active Comparator | Usual outpatient progress note with standard Subjective Objective Assessment Plan (SOAP) format |
|
| New template | Experimental | The assessment and plan section is placed in the beginning, subjective data grouped into the assessment section, and elements not related to the current presentation were deemphasized |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| New progress note template | Other | Residents assigned to document with new progress note template |
|
| Measure | Description | Time Frame |
|---|---|---|
| Note length | Note length in line count. | Duration of note entry, up to 2 hours |
| Time to note completion | Time to note completion in minutes. | Duration of note entry, up to 2 hours |
| Note evaluation by authors using a likert scale | Likert-scale survey instrument evaluating perceived organization, structure, and efficiency of note. | Immediately after note entry, up to 1 hour |
| Note evaluation by reviewers using the Physician Documentation Quality Instrument | Physician Documentation Quality Instrument (PDQI-9) - validated note quality scale composed of 9 metrics. 1 is not at all. 5 is extremely. | Within 1 year |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Jeremy A Epstein, MD | Johns Hopkins University | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Johns Hopkins Outpatient Center | Baltimore | Maryland | 21287 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 32901441 | Derived | Epstein JA, Cofrancesco J Jr, Beach MC, Bertram A, Hedian HF, Mixter S, Yeh HC, Berkenblit G. Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial. J Gen Intern Med. 2021 Mar;36(3):580-584. doi: 10.1007/s11606-020-06188-0. Epub 2020 Sep 8. |
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There is no sensitive or protected information. I am able to share any aspect of this trial to whomever would like to know more.
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| Standard progress note template | Other | Residents assigned to document with standard progress note template |
|