NCT04333238

Notation Optimization Through Template Engineering

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 36 (actual)
• Sponsor: Johns Hopkins University · Academic / Other
• Sex: All
• Age: —
• Healthy volunteers: Accepted

Summary

This is a randomized non-blinded controlled trial of a standard note template versus a redesigned note template using a simulated patient encounter and the electronic medical record.

Detailed description

Residents documented the simulated patient encounter using one of two templates. The standard template was based on the usual outpatient progress note. The new template placed the assessment and plan section in the beginning, grouped subjective data into the assessment section, and deemphasized elements not related to the current presentation.

Conditions

• Clinical Documentation

Interventions

Type	Name	Description
OTHER	New progress note template	Residents assigned to document with new progress note template
OTHER	Standard progress note template	Residents assigned to document with standard progress note template

Timeline

• Start date: 2017-01-20
• Primary completion: 2017-04-26
• Completion: 2018-12-01
• First posted: 2020-04-03
• Last updated: 2023-03-17

Locations

1 site across 1 country: United States