McRae Ashlyn E, Rowe Julian T, Friedes Barbara D, Abdul-Raheem Jareatha, Balighian Eric D, Bertram Amanda, Huang Victoria, McFarland Susan R, McDaniel Lauren M, Kumra Tina, Christopher Golden William, Pahwa Amit K
Johns Hopkins University School of Medicine (AE McRae, JT Rowe, BD Friedes, J Abdul-Raheem, and A Bertram), Baltimore, Md.
Johns Hopkins University School of Medicine (AE McRae, JT Rowe, BD Friedes, J Abdul-Raheem, and A Bertram), Baltimore, Md.
Acad Pediatr. 2023 Sep-Oct;23(7):1454-1458. doi: 10.1016/j.acap.2023.02.014. Epub 2023 Mar 11.
To determine whether a formal note-writing session and note template for medical students (MS) during the Core Clerkship in Pediatrics (CCP) increase note quality, shortens note length, and decreases time of documentation.
In this single site, prospective study, MS participating in an 8-week CCP received a didactic session on note-writing in the electronic health record (EHR) and utilized EHR template developed for the study. We assessed note quality (measured by Physician Documentation Quality Instrument-9 [PDQI-9]), note length and note documentation time in this group compared to MS notes on the CCP in the prior academic year. We used descriptive statistics and Kruskal-Wallis tests for analysis.
We analyzed 121 notes written by 40 students in the control group and 92 notes writing by 41 students in the intervention group. Notes from the intervention group were more "up to date," "accurate," "organized," and "comprehensible" compared to the control group (P = 0.02, P = 0.04, P = 0.01, and P = 0.02, respectively). Intervention group notes received higher cumulative PDQI-9 scores compared to the control group (median score 38 (IQR 34-42) versus 36 (IQR 32-40) out of 45 total, P = 0.04). Intervention group notes were approximately 35% shorter than the control group notes (median 68.5 lines vs 105 lines, P < 0.0001) and were signed earlier than control group notes (median file time 316 minute vs 352 minute, P = 0.02).
The intervention successfully decreased note length, improved note quality based on standardized metrics, and reduced time to completion of note documentation.
确定在儿科核心实习（CCP）期间为医学生（MS）安排正式的书写记录环节并提供记录模板，是否能提高记录质量、缩短记录长度并减少记录时间。
在这项单中心前瞻性研究中，参与为期8周CCP的MS接受了关于电子健康记录（EHR）中记录书写的教学课程，并使用了为该研究开发的EHR模板。与上一学年CCP中MS的记录相比，我们评估了该组的记录质量（通过医生记录质量工具-9 [PDQI-9] 衡量）、记录长度和记录时间。我们使用描述性统计和Kruskal-Wallis检验进行分析。
我们分析了对照组40名学生撰写的121份记录和干预组41名学生撰写的92份记录。与对照组相比，干预组的记录更“及时”、“准确”、“有条理”且“易懂”（P分别为0.02、0.04、0.01和0.02）。干预组记录的累积PDQI-9得分高于对照组（总分45分中，中位数得分38（四分位间距34 - 42）对36（四分位间距32 - 40），P = 0.04）。干预组的记录比对照组的记录短约35%（中位数68.5行对105行，P < 0.0001），且比对照组的记录签署时间更早（中位数存档时间316分钟对352分钟，P = 0.02）。
该干预成功缩短了记录长度，基于标准化指标提高了记录质量，并减少了完成记录的时间。
