Breithaupt Andrew, Mohan Sonam, Thombley Robert, Pimentel Samuel D, Douglas Vanja C
Department of Neurology, Emory University School of Medicine, Atlanta, GA.
Department of Neurology, Kaiser Permanente, San Jose, CA.
Neurol Educ. 2025 Mar 5;4(1):e200200. doi: 10.1212/NE9.0000000000200200. eCollection 2025 Mar.
Electronic health record documentation burden negatively affects physician satisfaction and patient care. Although well-constructed notes are important for care quality and safety, most note templates are created and maintained by individual physicians, leading to inefficiency and variable note quality. This study aimed to assess whether standardized, condition-specific note templates could enhance the efficiency and quality of notes written by neurology residents in the outpatient setting.
In a quality improvement study with a randomized, nonblinded design from July 2021 to June 2022, neurology residents were assigned standardized templates for epilepsy, headache, and Parkinson disease (PD) in 2 outpatient clinics. The standardized templates were created with input from specialists in these disorders. Efficiency was gauged based on the time and characters involved in note writing while quality was assessed by adherence to American Academy of Neurology quality metrics for each condition through chart review. A qualitative survey gathered resident opinions on the templates. Linear regression models were used in the efficiency and quality analyses.
The study included 23 of 34 neurology residents. Templates were used in 36% of eligible encounters over the first 6 months of the study and 65% over the last 6 months. No significant difference in time spent on note writing was observed between the template and nontemplate groups. While both groups showed similar quality measures across most domains, the template group documented quality measures more consistently for driving status in epilepsy (92% vs 53%, = 0.002), medication-related motor symptoms in PD (95% vs 50%, = 0.01), and lifestyle changes in headache management (77% vs 21%, = 0.005). Resident feedback suggested that the templates facilitated clinic workflows and prompted more thorough patient inquiry.
Standardized, condition-specific templates improved documentation of quality metrics without increasing time spent. Despite initial low uptake of template use, an increase was observed over time, indicating potential for wider acceptance with implementation efforts. These templates, updated and maintained by subject matter experts, serve as an opportunity to incorporate quality care checklists and knowledge into a clinician's workflow. This warrants further research into template implementation and its effects on care quality and education for neurologists and generalists.
电子健康记录文档负担对医生满意度和患者护理产生负面影响。尽管精心构建的记录对护理质量和安全很重要，但大多数记录模板是由个体医生创建和维护的，导致效率低下且记录质量参差不齐。本研究旨在评估标准化的、针对特定病症的记录模板是否能提高神经科住院医师在门诊环境中书写记录的效率和质量。
在一项2021年7月至2022年6月采用随机、非盲设计的质量改进研究中，神经科住院医师在两家门诊诊所被分配了针对癫痫、头痛和帕金森病（PD）的标准化模板。这些标准化模板是在这些疾病领域专家的参与下创建的。效率通过记录书写所涉及的时间和字符数来衡量，质量则通过病历审查中对每种病症遵循美国神经病学学会质量指标的情况进行评估。一项定性调查收集了住院医师对模板的意见。效率和质量分析采用线性回归模型。
该研究纳入了34名神经科住院医师中的23名。在研究的前6个月，36%的符合条件的诊疗使用了模板，后6个月这一比例为65%。模板组和非模板组在记录书写所花费的时间上没有观察到显著差异。虽然两组在大多数领域的质量指标相似，但模板组在癫痫驾驶状态（92%对53%，P = 0.002）、帕金森病药物相关运动症状（95%对50%，P = 0.01）以及头痛管理中的生活方式改变（77%对21%，P = 0.005）方面更一致地记录了质量指标。住院医师的反馈表明，模板促进了门诊工作流程，并促使对患者进行更全面的询问。
标准化的、针对特定病症的模板在不增加书写时间的情况下改善了质量指标的记录。尽管最初模板的使用率较低，但随着时间的推移有所增加，表明通过实施努力有更广泛接受的潜力。这些由主题专家更新和维护的模板，为将质量护理清单和知识纳入临床医生的工作流程提供了契机。这值得进一步研究模板的实施及其对神经科医生和全科医生护理质量和教育的影响。
