Notation Optimization Through Template Engineering (NOTE)

Johns Hopkins University

Status: Completed

Conditions: Clinical Documentation

Treatments: Other: Standard progress note template; Other: New progress note template

Study type: Interventional

Funder types: Other

Identifiers

NCT04333238

IRB00117171

Details and patient eligibility

About

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.

Full 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.

Enrollment: 36 patients

Sex: All

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

• Residents who had open visit slots during their outpatient clinic time

Exclusion criteria

• None

Trial design

Primary purpose: Other

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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36 participants in 2 patient groups

Standard template

Active Comparator group

Description:

Usual outpatient progress note with standard Subjective Objective Assessment Plan (SOAP) format

Treatment:

Other: Standard progress note template

New template

Experimental group

Description:

The assessment and plan section is placed in the beginning, subjective data grouped into the assessment section, and elements not related to the current presentation were deemphasized

Treatment:

Other: New progress note template