Department of Surgery, University of California San Francisco, San Francisco, California.
Division of Hospital Medicine, University of California San Francisco, San Francisco, California.
J Surg Educ. 2022 Nov-Dec;79(6):e257-e262. doi: 10.1016/j.jsurg.2022.08.011. Epub 2022 Sep 9.
Daily progress notes are the backbone of all inpatient hospitalizations. Progress notes serve as a lasting record of a patient's diagnoses, condition, and planned interventions and are essential communication tools. We designed a study to identify patterns in progress note filing and use on general surgical services.
The electronic health record (EHR) data warehouse was queried for general surgical progress notes signed between July 1, 2020, and July 1, 2021. Only notes authored by resident physicians or advanced practice providers (APPs) were included, and those filed on the day of a surgery were excluded. 10 am was identified as a target for note completion as it coincided with multidisciplinary discharge rounds. Physician, case managers pharmacist, physical therapist, dietician, nurse (and collaborating disciplines) progress note views were measured using EHR access log data.
A total of 8384 progress notes were analyzed; 4146 notes (49%) were authored by 81 trainees. A total of 4433 (53%) progress notes were filed before 10 am, 3673 (44%) were filed between 10 am and 6 pm, and 278 (3%) were filed after 6 pm. Variation in progress note file time was observed and associated with individual habits, residents vs APPs, day-of-week, and service structure. Surgery progress notes are viewed by collaborating disciplines throughout the workday, with high-volume viewership occurring by mid-morning. Each individual progress note received an average of 17.6 lifetime views with a range of 1 to 76. An average of 10.2 of those views occurred on the same day that the note was written. Notes that were filed after 10 am received a significantly lower number of same-day views compared to notes filed before 10am (8.4 vs 11.8, p < 0.0001).
Progress notes are identified as a significant burden by trainees and even considered to contribute to duty hour violations, yet they are used regularly as a source of information for collaborating disciplines. Progress notes filed earlier are viewed more frequently. Efforts to identify barriers to timeliness may help communication and efficiency of inpatient surgical care.
每日病程记录是所有住院治疗的基础。病程记录作为患者诊断、病情和计划干预措施的持久记录，是至关重要的沟通工具。我们设计了一项研究，旨在确定普通外科服务中病程记录归档和使用的模式。
从 2020 年 7 月 1 日至 2021 年 7 月 1 日期间，对电子健康记录（EHR）数据库中普通外科的病程记录进行查询。仅包括由住院医师或高级执业医师（APP）撰写的记录，并且排除在手术当天归档的记录。上午 10 点被确定为完成记录的目标时间，因为此时恰逢多学科出院查房。使用 EHR 访问日志数据测量医师、病例管理员、药剂师、物理治疗师、营养师、护士（和协作学科）的病程记录视图。
共分析了 8384 份病程记录，其中 4146 份（49%）由 81 名受训者撰写。共有 4433 份（53%）病程记录在上午 10 点之前归档，3673 份（44%）在上午 10 点至下午 6 点之间归档，278 份（3%）在下午 6 点之后归档。观察到病程记录归档时间存在差异，并与个人习惯、住院医师与 APP、工作日和服务结构有关。协作学科全天查看手术病程记录，上午中旬时高容量查看。每份病程记录的平均总查看次数为 17.6 次，范围为 1 到 76 次。平均有 10.2 次查看发生在记录当天。与上午 10 点之前归档的记录相比，上午 10 点之后归档的记录当天的查看次数明显较少（8.4 次与 11.8 次，p<0.0001）。
受训者认为病程记录是一项重大负担，甚至认为这是造成超时工作的原因之一，但病程记录经常被用作协作学科的信息来源。较早归档的病程记录被查看的频率更高。确定及时性障碍的努力可能有助于改善住院外科护理的沟通和效率。
