JMIR Publications

ABSTRACT

Background:

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

Objective:

We sought to describe hospital progress note content, writing and reading practices, and preferences of those who create and read them in advance of implementation of a new EHR.

Methods:

DESIGN Analysis of all hospital progress notes from 1,000 randomly selected admissions to the Medical service and focus groups. MAIN MEASURES We measured note length, similarity of content in successive daily notes in the same patient, the time notes were signed and read, and who read them. We conducted focus groups of note writers, readers, and clinical leaders to understand their preferences.

Results:

We analyzed 4,938 inpatient progress notes from 418 authors. Average length was 886 words; most was in the Assessment and Plan. Twenty-nine percent of notes 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% had clinical risk associated with preserved content. Content of highest varies by the reader’s professional role.

Conclusions:

Progress note length varies widely. Notes are often signed late in the day when they are read less often and are highly similar to the note from the previous day. Measuring note length, signing time, when and by whom notes are read and amount and safety of preserved content will be useful metrics in our new EHR.