News: Writing clinical notes at a dedicated time can improve efficiency, study shows

A study published by the Journal of the American Medical Informatics Association (JAMIA) found that clinician documentation styles can impact providers’ work hours and administrative burden. Specifically, writing clinical notes at one dedicated time during the day, instead of varying times, led to decreased EHR documentation times.

The study examined progress note production styles for internal medicine residents at the University of California, San Francisco, covering 279 inpatient encounters. Those residents who tended to write their notes dispersed throughout the day tended to work more hours. Residents who wrote their notes at a dedicated, uninterrupted session in the morning or afternoon spent less time working each day.

According to the study, those residents who documented in a style that was dispersed throughout the day may spend more time at work because of task-switching, such as spending more time re-reviewing patient history and notes when coming back to notetaking.

The study also found that residents who wrote their notes in short sessions later in the evening tended to spend more time notetaking overall because of the greater need to recall specific information from a patient visit earlier in the day.

The results suggest that “note writing behaviors should be further investigated to understand what practices could be targeted to reduce documentation burden and derivative outcomes such as resident work hour violations.” Further research could not only impact future EHR and documentation training for clinicians, but also reveal documentation methods that are likely to cause the least amount of provider burnout.

Editor’s note: The full JAMIA study can be found here. More ACDIS coverage of provider burnout can be found here.