News

When and how you write up your clinical notes may have a bigger impact on your long-term wellbeing at work than thought, accordingly to a recently released study. 

A study published in the Journal of the American Medical Informatics Association tracked the progress note production styles of internal medicine residents at UC San Francisco during three two-week periods. The notes covered 279 inpatient encounters. The study found that residents who wrote notes throughout the day registered more clinical time. The study posits this is likely due to residents needing to start and stop their notations and needing to re-read information before making additional notes. This time spent reviewing previous entries meant more clinical time, especially in the evening.

For those residents who dedicated set time during the day for notetaking, the study found those who focused during the morning or afternoon spent less time "at work" than those who dedicated time in the evening to clinical notes. The authors suggest this is due to more recall needed during the evening, when residents would have to "jog their memory" on what they wrote and why. Instead, dedicating time during work hours allowed residents to write more contemporary notes and require less recall.

The authors also suggest this could impact best practices for EHR documentation. Rather than templates or set requirements for documenting information in an EHR, the authors suggest that how notes are done may have a bigger impact on medical errors and burnout.

Read the study here.