Objective

To assess physicians’ perceptions about narrative note sections format and content commonly reported in visit notes to inform future research and EHR development.

Methods

We conducted two online surveys with a multi-specialty panel of outpatient physicians from a large health system to collect their perceptions of the usefulness of three narrative formats and the relevance of content reported in the note sections history of present illness (HPI) and assessment and plan (AP). Survey questions were responded with a 7-point Likert scale and include two open-ended questions for comments on challenges and suggestions related to electronic clinical documentation.

Results

Eighty-eight physicians completed the surveys. The most preferred format for HPI was story (i.e., coherent paragraph), followed by list without categories (i.e., non-categorized sentences) and list with categories (i.e., categorized sentences). The most preferred format for AP was list with categories, followed by story and list without categories. The most relevant type of content in HPI was temporal information and finding/condition. The most relevant type of content reported in AP was intervention and reasons and justifications. Challenges frequently mentioned include suboptimal note creation interfaces and bloated notes, and the most common suggestions for improvements are related to note entry facilitators and organizational improvements.

Conclusion

Physicians’ input is extremely valuable to inform improvements to EHRs. More effective clinical documentation systems should include less intrusive, more intuitive and automated user interfaces for note creation, smarter autopoluation functionality and linkage between note content and data from other parts of the record.

中文翻译：

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医师对叙事笔记部分的格式和内容的看法：一项多专业调查

客观的

评估医师对叙事笔记章节格式和内容的常识，这些笔记和格式通常会在访视笔记中报告，以为将来的研究和EHR开发提供参考。

方法

我们对来自大型卫生系统的门诊医生的多专业小组进行了两次在线调查，以收集他们对三种叙述形式的用处以及当前病史（HPI），注释和评估的注释部分中所报告内容的相关性的看法。计划（AP）。调查问题以7点李克特量表进行了回答，其中包括两个开放式问题，以就与电子临床文档有关的挑战和建议发表意见。

结果

88名医生完成了调查。HPI最优选的格式是故事（即，连贯的段落），其次是没有类别的列表（即，未分类的句子）和具有类别的列表（即，已分类的句子）。AP最喜欢的格式是带有类别的列表，其次是故事和没有类别的列表。HPI中最相关的内容类型是时间信息和查找/条件。AP中报告的最相关的内容类型是干预措施，原因和理由。经常提到的挑战包括次优的便笺创建界面和过分的便笺，最常见的改进建议与便笺输入促进者和组织改进有关。

结论

医师的意见对于改善EHR具有极为重要的意义。更有效的临床文档系统应该包括用于创建便笺的侵入性更强，更直观和自动化的用户界面，更智能的自动极化功能以及便笺内容与记录中其他部分的数据之间的链接。