Physicians' perceptions about narrative note sections format and content: A multi-specialty survey

Abstract

Objective: To assess physicians' perceptions about narrative note sections format and content commonly reported in visit notes to inform future research and EHR development.

Methods: We conducted two online surveys with a multi-specialty panel of outpatient physicians from a large health system to collect their perceptions of the usefulness of three narrative formats and the relevance of content reported in the note sections history of present illness (HPI) and assessment and plan (AP). Survey questions were responded with a 7-point Likert scale and include two open-ended questions for comments on challenges and suggestions related to electronic clinical documentation.

Results: Eighty-eight physicians completed the surveys. The most preferred format for HPI was story (i.e., coherent paragraph), followed by list without categories (i.e., non-categorized sentences) and list with categories (i.e., categorized sentences). The most preferred format for AP was list with categories, followed by story and list without categories. The most relevant type of content in HPI was temporal information and finding/condition. The most relevant type of content reported in AP was intervention and reasons and justifications. Challenges frequently mentioned include suboptimal note creation interfaces and bloated notes, and the most common suggestions for improvements are related to note entry facilitators and organizational improvements.

Conclusion: Physicians' input is extremely valuable to inform improvements to EHRs. More effective clinical documentation systems should include less intrusive, more intuitive and automated user interfaces for note creation, smarter autopoluation functionality and linkage between note content and data from other parts of the record.

Keywords: Clinical documentation; Electronic health records; Outpatient care; Physicians’ perceptions; Visit note.