Electronic health records should efficiently store the information required for clinical decision-making and contain progress notes that reference this information. However, beyond the inclusion of subjective data, objective data, assessment, and plan framework, the content required to make progress notes useful for readers with diverse specialties has not been clarified. Moreover, the documentation burden that including additional content places on medical doctors (MDs) has not been determined. We conducted a questionnaire with 74 MDs, nurses, and other clinical professionals to determine whether they found progress notes with varying specific contents useful. In addition, the degree of the burden of writing progress notes that contain specific content was measured when 25 MDs were instructed to add specific content. Our results reveal that progress notes are more useful for clinical reasoning for readers other than MDs when more specific information is included; this can be achieved without increasing the documentation burden.
Keywords: Clinical Decision-Making; Clinical Reasoning; Electronic Health Records.