Ebbers T, Kool RB, Smeele LE, Dirven R, den Besten CA, Karssemakers LHE, Verhoeven T, Herruer JM, van den Broek GB, Takes RP, et al.
Journal of medical systems. Date of publication 2022 May 27;volume 46(7):46.
1. J Med Syst. 2022 May 27;46(7):46. doi: 10.1007/s10916-022-01837-9.
The Impact of Structured and Standardized Documentation on Documentation
Quality; a Multicenter, Retrospective Study.
Ebbers T(1), Kool RB(2), Smeele LE(3), Dirven R(3), den Besten CA(3),
Karssemakers LHE(3), Verhoeven T(4), Herruer JM(5), van den Broek GB(5), Takes
RP(5).
Author information:
(1)Department of Otorhinolaryngology and Head and Neck Surgery, Radboud
University Medical Center, Nijmegen, Netherlands. tom.ebbers@radboudumc.nl.
(2)Radboud University Medical Center, Radboud Institute for Health Sciences, IQ
Healthcare, Nijmegen, Netherlands.
(3)Department of Head and Neck Oncology and Surgery, Antoni Van Leeuwenhoek,
Amsterdam, Netherlands.
(4)Department of Oromaxillofacial Surgery and Head and Neck Surgery, Radboud
University Medical Center, Nijmegen, Netherlands.
(5)Department of Otorhinolaryngology and Head and Neck Surgery, Radboud
University Medical Center, Nijmegen, Netherlands.
The reuse of healthcare data for various purposes will become increasingly
important in the future. To enable the reuse of clinical data, structured and
standardized documentation is conditional. However, the primary purpose of
clinical documentation is to support high-quality patient care. Therefore, this
study investigated the effect of increased structured and standardized
documentation on the quality of notes in the Electronic Health Record. A
multicenter, retrospective design was used to assess the difference in note
quality between 144 unstructured and 144 structured notes. Independent reviewers
measured note quality by scoring the notes with the Qnote instrument. This
instrument rates all note elements independently using and results in a grand
mean score on a 0-100 scale. The mean quality score for unstructured notes was
64.35 (95% CI 61.30-67.35). Structured and standardized documentation improved
the Qnote quality score to 77.2 (95% CI 74.18-80.21), a 12.8 point difference
(p < 0.001). Furthermore, results showed that structured notes were
significantly longer than unstructured notes. Nevertheless, structured notes
were more clear and concise. Structured documentation led to a significant
increase in note quality. Moreover, considering the benefits of structured data
recording in terms of data reuse, implementing structured and standardized
documentation into the EHR is recommended.
© 2022. The Author(s).
DOI: 10.1007/s10916-022-01837-9
PMCID: PMC9135789
PMID: 35618978 [Indexed for MEDLINE]
Conflict of interest statement: None declared.
