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Last updated on April 16, 2014 at 12:50 EDT

Doctors Who Dictate Patient Notes

May 22, 2012

To dictate or not to dictate?

Could the quality of care you receive be affected by how your doctor takes notes? According to a new study by researchers at Brigham and Women’s Hospital (BWH), doctors who dictated their patient notes appeared to have worse quality of care than those who used structured documentation.

The study is published online in the Journal of the American Medical Informatics Association.

The researchers evaluated 18,569 visits by 7,000 patients with coronary artery disease and diabetes to participating physicians in a regional healthcare delivery network in eastern Massachusetts. Of these 234 doctors in the study, 20 (9 percent) dictated their notes, 68 (29 percent) used structured documentation, and146 (62 percent) typed free-text notes.

Dictation was done via telephone and transcribed and uploaded to the electronic health record (EHR). Structured documentation involved using templates that divided the patient visit note into separate sections (e.g., history of present illness, review of systems, family history, etc.) for the doctor to fill in.  Free-text notes were created using a single window, similar to a word-processing program.

The main outcome measures were 15 coronary artery disease and diabetes measures assessed 30 days after primary care visits.

Compared to the other two documentation styles, quality of care was significantly worse on three outcome measures for dictators. These measures were antiplatelet medication, tobacco use documentation and diabetic eye exam.

Quality of care was better on three measures for doctors who used structured documentation. These measures were blood pressure documentation, body mass index documentation and diabetic foot exam. Doctors who used free-text notes had better quality of care in providing influenza vaccinations.

There was no measure associated with higher quality of care for doctors who dictated their notes.

“Dictating may be easier for the doctor, but patients need to be careful,” said Jeffrey Linder, MD, associate professor of medicine at BWH and Harvard Medical School, and lead study author. “Doctors who dictate may not be paying as close attention to information and alerts in the electronic health record that are important for patient health.”

This research was supported by the Agency for Healthcare Research and Quality and the National Heart, Lung and Blood Institute.

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