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OpenTrials
Completed

NCT Number: NCT01958723

Problem Specific Templates for Electronic Hospital Documentation

The emergence of electronic documentation has led to multiple new challenges for physicians. Despite positive expectations, many physicians have received electronic health systems with mixed results. Review of current literature has identified the following reasons for concern: increased time required for documentation, deteriorating quality of notes, mindless use of copy-and-paste functions, and fragmentation of clinical work from poorly designed computing workflows. The study of template use has not been done in a large scale or with clear outcome measurements. The purpose of this study is to examine the effects of Problem Specific Templates on quality, accuracy, and efficiency of physician documentation practices.

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Key information

Conditions

Quality/Accuracy of Physician Documentation Efficiency of Physician Documentation

Age range

18 year–70 year

Sex eligibility

All sexes

Study type

Observational

Primary location

University of Florida

Gainesville, Florida, 32611, United States

About this study

This is a prospective cohort study, which will examine the effects of Problem Specific Templates on quality, accuracy, and efficiency of physician documentation practices. The Hospitalist physicians will be the subjects. All physicians of the Hospital Medicine Service will be invited to participate. For the intervention, participating Hospitalists will be trained on the use of templates for 20 common hospital problems. Once trained, the Hospitalists will be asked to use these templates for a one-month period. Pre-intervention and post-intervention medical records will be compared using chart reviews, validated document assessment instruments, physician surveys, and electronic medical record time auditing.

Who can participate

Healthy volunteers accepted: Yes

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Physicians: All physicians of the Hospital Medicine Service will be invited to participate

Exclusion criteria

  • Any invited physicians who refuse to consent

Treatment and study plan

Hospitalists

Other

Introduction of Problem Specific Templates

Primary outcomes

  1. Quality and Accuracy of Physician Documentation Practices (as measured through chart review)

    Time frame: 1 year

  2. Efficiency of Physician Documentation Practices (as measured through the electronic medical record auditing function)

    Time frame: 1 year

Secondary outcomes

  1. Frequency of Physician Use of Problem Specific Templates (as measured through chart review)

    Time frame: 1 year

  2. Physician Assessment of Note-Documenting and Electronic Medical Record (as measured through Physician Questionnaire)

    Time frame: 1 year

Sponsors and collaborators

Lead sponsor

University of Florida

Other

Registry information

Important dates

Study start
2013
Primary completion
2014
Study completion
2014
First posted
Oct 9, 2013
Registry last updated
Apr 13, 2015

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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