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.
IOS Press, Inc.
6751 Tepper Drive
Clifton, VA 20124
Tel.: +1 703 830 6300
Fax: +1 703 830 2300 firstname.lastname@example.org
(Corporate matters and books only) IOS Press c/o Accucoms US, Inc.
For North America Sales and Customer Service
West Point Commons
Lansdale PA 19446
Tel.: +1 866 855 8967
Fax: +1 215 660 5042 email@example.com