The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency.
Publication/Presentation Date
1-1-2013
Abstract
Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation. Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5% and 60% to 100% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3% to 0% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming electronic progress note.
Volume
28
Issue
1
First Page
25
Last Page
32
ISSN
1555-824X
Published In/Presented At
Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., & Riggio, J. M. (2013). The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency. American journal of medical quality : the official journal of the American College of Medical Quality, 28(1), 25–32. https://doi.org/10.1177/1062860612445307
Disciplines
Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods
PubMedID
22684012
Department(s)
Administration and Leadership
Document Type
Article