Oregon Health & Science University, Portland, OR.
AMIA Annu Symp Proc. 2022 Feb 21;2021:1059-1068. eCollection 2021.
Working with scribes can reduce provider documentation time, but few studies have examined how scribes affect clinical notes. In this retrospective cross-sectional study, we examine over 50,000 outpatient progress notes written with and without scribe assistance by 70 providers across 27 specialties in 2017-2018. We find scribed notes were consistently longer than those written without scribe assistance, with most additional text coming from note templates. Scribed notes were also more likely to contain certain templated lists, such as the patient's medications or past medical history. However, there was significant variation in how working with scribes affected a provider's mix of typed, templated, and copied note text, suggesting providers adapt their documentation workflows to varying degrees when working with scribes. These results suggest working with scribes may contribute to note bloat, but that providers' individual documentation workflows, including their note templates, may have a large impact on scribed note contents.
使用抄写员可以减少提供者的文件记录时间，但很少有研究检查抄写员如何影响临床记录。在这项回顾性的横断面研究中，我们检查了 2017 年至 2018 年间 27 个专业的 70 名提供者在有和没有抄写员协助的情况下记录的超过 50,000 份门诊进度记录。我们发现，有抄写员协助的记录通常比没有抄写员协助的记录更长，大多数额外的文本来自记录模板。有抄写员协助的记录也更有可能包含某些模板列表，例如患者的药物或既往病史。然而，抄写员对提供者的记录工作流程的影响存在显著差异，这表明提供者在使用抄写员时在不同程度上适应了他们的文件记录工作流程。这些结果表明，使用抄写员可能导致记录膨胀，但提供者的个人文件记录工作流程，包括他们的记录模板，可能对记录的内容有很大的影响。
