Impact of clinical note format on diagnostic accuracy and efficiency

In: Health information management journal, Volume 53, Issue 3, p. 183-188

Abstract

Background Clinician notes are structured in a variety of ways. This research pilot tested an innovative study design and explored the impact of note formats on diagnostic accuracy and documentation review time. Objective To compare two formats for clinical documentation (narrative format vs. list of findings) on clinician diagnostic accuracy and documentation review time. Method Participants diagnosed written clinical cases, half in narrative format, and half in list format. Diagnostic accuracy (defined as including correct case diagnosis among top three diagnoses) and time spent processing the case scenario were measured for each format. Generalised linear mixed regression models and bias-corrected bootstrap percentile confidence intervals for mean paired differences were used to analyse the primary research questions. Results Odds of correctly diagnosing list format notes were 26% greater than with narrative notes. However, there is insufficient evidence that this difference is significant (75% CI 0.8–1.99). On average the list format notes required 85.6 more seconds to process and arrive at a diagnosis compared to narrative notes (95% CI -162.3, −2.77). Of cases where participants included the correct diagnosis, on average the list format notes required 94.17 more seconds compared to narrative notes (75% CI -195.9, −8.83). Conclusion This study offers note format considerations for those interested in improving clinical documentation and suggests directions for future research. Balancing the priority of clinician preference with value of structured data may be necessary. Implications This study provides a method and suggestive results for further investigation in usability of electronic documentation formats.