Vaid Monica M, Kisuule Flora, Kantisper Melinda, Tackett Sean, Durso Samuel Christopher, Wright Scott M
Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, and Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, and Johns Hopkins University School of Medicine, Baltimore, MD, USA.
J Gen Intern Med. 2025 May 9. doi: 10.1007/s11606-025-09558-8.
Progress notes written about hospitalized patients are suboptimal. Notes are bloated and awash with inaccuracies. Poor notes negatively impact patient care.
To design and assess a progress note scoring rubric and educational intervention aimed at improving the quality of progress notes.
Randomized control educational trial.
Hospitalist physicians at a large academic medical center.
Hospitalists were randomized to either a multi-pronged educational intervention or the control group.
A scoring rubric was developed to measure the quality of progress notes; validity evidence was established for the measure. This rubric was used by assessors (blinded to both group and pre/post periods) to evaluate progress notes. Notes were pulled from 6 months before and after the intervention period (n = 156 notes).
Of the 26 participating hospitalists, 14 were randomized to the intervention. The two groups of hospitalists were similar in terms of age, gender, and clinical experience (all p > 0.05). Both groups had comparable notes at baseline (total score, 0.32 vs. 0.30, p = 0.59). After participating in the educational session, all 14 of the rubric items were higher in the intervention group-both compared to the control group and to their baseline/PRE notes-many changes reaching statistical significance. Total scores for the intervention group improved significantly (all p < 0.05). The instruments' total score and global rating of "how well the note would prepare the next provider to take over the care of the patient" were highly correlated-0.72. Note length was not extended by the intervention (p > 0.05).
This work established both an objective scoring rubric to assess the quality of progress notes and an efficient, impactful method for coaching hospitalists. For other groups striving to improve progress note quality, this study provides a blueprint for how they might proceed.
关于住院患者的病程记录质量欠佳。记录冗长且存在大量不准确信息。质量差的记录会对患者护理产生负面影响。
设计并评估一个旨在提高病程记录质量的病程记录评分量表及教育干预措施。
随机对照教育试验。
一家大型学术医疗中心的住院医师。
住院医师被随机分为多方面教育干预组或对照组。
制定了一个评分量表来衡量病程记录的质量；为该量表建立了效度证据。评估人员（对分组及干预前后阶段均不知情）使用此量表来评估病程记录。在干预期前后6个月抽取记录（n = 156份记录）。
26名参与研究的住院医师中，14名被随机分配到干预组。两组住院医师在年龄、性别和临床经验方面相似（所有p > 0.05）。两组在基线时的记录具有可比性（总分，0.32对0.30，p = 0.59）。参加教育课程后，干预组的所有14个量表项目得分均高于对照组以及干预组自身的基线/预干预记录，许多变化具有统计学意义。干预组的总分显著提高（所有p < 0.05）。该工具的总分与“该记录能让下一位医护人员接手患者护理工作的程度”的整体评分高度相关，相关系数为0.72。干预并未延长记录长度（p > 0.05）。
本研究既建立了一个评估病程记录质量的客观评分量表，又建立了一种指导住院医师的高效且有效的方法。对于其他致力于提高病程记录质量的群体而言，本研究为他们的实施方式提供了蓝本。
