Notation Optimization Through Template Engineering

Clinical Documentation Clinical Trial

— NOTE  

Official title:

Notation Optimization Through Template Engineering

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT04333238
• Other study ID #: IRB00117171
• Status: Completed
• Phase: N/A
• Start date: January 20, 2017
• Est. completion date: December 1, 2018

Study information

• Verified date: April 2020
• Source: Johns Hopkins University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

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.

Description:

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.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 36
• Est. completion date: December 1, 2018
• Est. primary completion date: April 26, 2017
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: N/A and older

Eligibility

Inclusion Criteria:

• Residents who had open visit slots during their outpatient clinic time

Exclusion Criteria:

• None

Related Conditions & MeSH terms

• Clinical Documentation

Intervention

Other:
• New progress note template
Residents assigned to document with new progress note template
• Standard progress note template
Residents assigned to document with standard progress note template

Locations

Country	Name	City	State
United States	Johns Hopkins Outpatient Center	Baltimore	Maryland

Sponsors (1)

Lead Sponsor	Collaborator
Johns Hopkins University

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Note length	Note length in line count.	Duration of note entry, up to 2 hours
Primary	Time to note completion	Time to note completion in minutes.	Duration of note entry, up to 2 hours
Primary	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
Primary	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