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OpenTrials
Completed

NCT Number: NCT04333238

Notation Optimization Through Template Engineering

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.

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Key information

Conditions

Clinical Documentation

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Johns Hopkins Outpatient Center

Baltimore, Maryland, 21287, United States

About this study

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.

Who can participate

Healthy volunteers accepted: Yes

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

Inclusion criteria

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

Exclusion criteria

  • None

Treatment and study plan

New progress note template

Other

Residents assigned to document with new progress note template

Standard progress note template

Other

Residents assigned to document with standard progress note template

Primary outcomes

  1. Note length

    Time frame: Duration of note entry, up to 2 hours

    Note length in line count.

  2. Time to note completion

    Time frame: Duration of note entry, up to 2 hours

    Time to note completion in minutes.

  3. Note evaluation by authors using a likert scale

    Time frame: Immediately after note entry, up to 1 hour

    Likert-scale survey instrument evaluating perceived organization, structure, and efficiency of note.

  4. Note evaluation by reviewers using the Physician Documentation Quality Instrument

    Time frame: Within 1 year

    Physician Documentation Quality Instrument (PDQI-9) - validated note quality scale composed of 9 metrics. 1 is not at all. 5 is extremely.

Sponsors and collaborators

Lead sponsor

Johns Hopkins University

Other

Registry information

Acronym: NOTE

Important dates

Study start
2017
Primary completion
2017
Study completion
2018
First posted
Apr 3, 2020
Registry last updated
Mar 17, 2023

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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