Writing Practices Associated With Electronic Progress Notes and the Preferences of Those Who Read Them: Descriptive Study

Abstract

Background: Hospital progress notes can serve as an important communication tool. However, they are criticized for their length, preserved content, and for the time physicians spend writing them.

Objective: We aimed to describe hospital progress note content, writing and reading practices, and the preferences of those who create and read them prior to the implementation of a new electronic health record system.

Methods: Using a sample of hospital progress notes from 1000 randomly selected admissions, we measured note length, similarity of content in successive daily notes for the same patient, the time notes were signed and read, and who read them. We conducted focus group sessions with note writers, readers, and clinical leaders to understand their preferences.

Results: We analyzed 4938 inpatient progress notes from 418 authors. The average length was 886 words, and most were in the Assessment & Plan note section. A total of 29% of notes (n=1432) were signed after 4 PM. Notes signed later in the day were read less often. Notes were highly similar from one day to the next, and 26% (23/88) had clinical risk associated with the preserved content. Note content of the highest value varied according to the reader's professional role.

Conclusions: Progress note length varied widely. Notes were often signed late in the day when they were read less often and were highly similar to the note from the previous day. Measuring note length, signing time, when and by whom notes are read, and the amount and safety of preserved content will be useful metrics for measuring how the new electronic health record system is used, and can aid improvements.

Keywords: EHR; clinical communication; copy-paste; electronic documentation; electronic health records; hospital; hospital progress notes; human factors; patient records; physician communication; workflow.