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Sarah Glass, Adam Rule, Michelle Hribar, Thomas S Hwang, Michael F. Chiang; Electronic Health Records in Ophthalmology: Quantitative evaluation of progress note utility for clinical decision-making. Invest. Ophthalmol. Vis. Sci. 2020;61(7):5113.
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The progress note is the primary method of documenting the provider’s findings and clinical reasoning in a patient’s chart. With the advent of electronic health records (EHR), chart notes have become increasingly lengthy, potentially obscuring clinically useful information. The aim of our study was to identify the portions of ophthalmology progress notes that clinicians find most critical for clinical decision-making using quantitative analysis methods.
We performed a search of comprehensive ophthalmology chart notes from established adult patients using Oregon Health & Science University’s (OHSU) Epic database from 2017-2018. 330 notes matched search criteria. Ophthalmologists reviewed 3 de-identified representative examples, identifying text they considered critical to understanding the clinical reasoning in the patient encounter and text they deemed not useful for decision making. The highlighted text was quantitatively and qualitatively assessed. The study was approved by the OHSU Institutional Review Board.
Nine participants each reviewed 3 chart notes for a total of 27 notes. Each note contained a mean of 1286.3 words, of which 355.6 words (27.8%) were marked critical to decision making, 172.0 words (13.8%) were marked not useful, and 758.7 words (59.1%) were left unmarked. The assessment, exam, and plan were most commonly marked as critical in 100%, 96%, and 85% of notes, respectively. Reference statements, medical history, and attestations were most commonly considered not useful in 56%, 56%, and 44% of notes, respectively. The longest note section was current medications (21.4% of total words). The plan section comprised only 2.5% of the note but was considered critical in 88% of notes with a mean 82.1% of words marked. In contrast, current medications were marked critical in only 22.2% of notes with a mean 12.5% of words marked.
The study provides a quantitative assessment of the content of clinical notes. While significant variability exists in the note review, the sections of the note considered critical were the exam, assessment and plan, and a small percentage of note text was deemed critical information by clinicians. These findings may better inform EHR best practices and design improvement, and may impact policymaking regarding clinical documentation.
This is a 2020 ARVO Annual Meeting abstract.
Quantification and classification of information contained in chart notes
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