Notation Optimization Through Template Engineering

NCT04333238 | Completed

• 1 other identifier: IRB00117171
• Study Type: interventional
• Target: 36
• Locations: 1 country
• Sites: 1

Brief 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.

Conditions

Clinical Documentation

Keywords

Progress note; Note template; Electronic medical record; Note quality

Outcome Measures

Primary Outcomes (4)

• 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

Study Arms (2)

Standard template

ACTIVE COMPARATOR

Usual outpatient progress note with standard Subjective Objective Assessment Plan (SOAP) format

Other: Standard progress note template

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

Other: New progress note template

Interventions

New progress note template OTHER

Residents assigned to document with new progress note template

New template

Standard progress note template OTHER

Residents assigned to document with standard progress note template

Standard template

Eligibility Criteria

• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)

You may qualify if:

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

You may not qualify if:

• None

Sponsors & Collaborators

• Johns Hopkins University: lead

Study Sites (1)

Johns Hopkins Outpatient Center

Baltimore, Maryland, 21287, United States

Location

Related Publications (1)

• 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.

  PMID: 32901441 DERIVED

Study Officials

• Jeremy A Epstein, MD

  Johns Hopkins University

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: OTHER
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: March 29, 2020
• First Posted: April 3, 2020
• Study Start: January 20, 2017
• Primary Completion: April 26, 2017
• Study Completion: December 1, 2018
• Last Updated: March 17, 2023

Record last verified: 2020-04

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL

Locations

US (1)