Study: Doctors’ note-taking habits could hurt Chicago patients

Quality patient care is expected of Chicago health care providers. A correct diagnosis, precise drug prescriptions and careful attention to treatment are all part of doctors’ promised commitments to patients. A medical error in any of these duties could be construed as malpractice and cause harm to patients.

Physicians are also expected to communicate effectively with their patients so that patients understand the illnesses or injuries they face. Clear communication includes proper note-taking by doctors to accurately document patient visits and health concerns. According to a recent study, doctors who dictate or free-text patient notes delivered poorer quality care to patients compared to physicians who used structured note-taking methods.

For the study, researchers gathered information from doctors’ visits for about 7,000 patients who suffered from diabetes and heart disease. The data included reviews of more than 230 doctors using electronic health records and over 188,000 patient visit notes.

Researchers discovered that almost two-thirds of the doctors, 62 percent, took “free-text” notes — a simplified system of note-taking on a single computer window. Nine percent dictated notes into phones, which were later transcribed and entered in electronic medical records. The remaining 29 percent recorded notes methodically using a multi-window format that sectioned patient information into organized categories.

Researchers tracked patient charts for 30 days to see whether more than a dozen disease-related “outcome measures” were documented properly. Doctors who recorded electronic notes in a structured format showed a far higher quality of care on three of 15 measures, including blood pressure documentation. Thirty-eight percent of structured note-takers uploaded information about patients’ use of tobacco. Just 22 percent of dictating doctors included patients’ tobacco data.

According to the results of the study, physicians who used dictation were consistently behind in health care quality compared to doctors who updated notes directly into electronic patient records.

Although doctors may prefer a certain method for note-taking, they should always make sure that their notes are accurate and descriptive in order to ensure that patients’ conditions and visits are documented properly. Detailed notes could end up saving a patient’s life.

Source: American Medical News, “Doctors’ EHR note-taking method affects quality of care,” Christine S. Moyer, June 12, 2012

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