Designing a physician's daily note template to support higher quality documentation of patient information

摘要

Computerized medical records are continuing to be adopted in hospitals nationwide, but the vast majority of health care systems rely on paper records as well. Physician documentation of patient conditions must support a variety of functions, which often conflict with each other. The goal of this project was to redesign the daily note template for a Trauma Center to encourage higher quality documentation of patient information. This, in turn, supports patient care, physicians' training, standardization of information, the hospital's billing, and legal records. The authors' methodology was to assess the residents' current routine and conduct focus groups with Trauma residents and attendings to shape the design of the new note to encourage higher quality documentation that follows a systems-based approach to evaluating the patient.