Talk to the Veterans Crisis Line now
An official website of the United States government
Search | Search by Center | Search by Source | Keywords in Title
Saleem JJ, Adams S, Frankel RM, Doebbeling BN, Patterson ES. Efficiency strategies for facilitating computerized clinical documentation in ambulatory care. Studies in health technology and informatics. 2013 Jan 1; 192:13-7.
Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Most providers have experienced increased documentation demands with the use of electronic health records (EHRs). We sought to identify efficiency strategies that providers use to complete clinical documentation tasks in ambulatory care. Two observers performed ethnographic observations and interviews with 22 ambulatory care providers in a U.S. Veterans Affairs Medical Center. Observation notes and interview transcripts were coded for recurrent strategies relating to completion of the EHR progress notes. Findings included: the use of paper artifacts for handwritten notations; electronic templates for automation of certain parts of the note; use of shorthand and phrases rather than narrative writing; copying and pasting from previous EHR notes; directly entering information into the EHR note during the patient encounter; reliance on memory; and pre-populating an EHR note prior to seeing the patient. We discuss the findings in the context of distributed cognition to understand how clinical information is propagated and represented toward completion of a progress note. The study findings have important implications for improving and streamlining clinical documentation related to human factors workload management strategies.
