Case Notes From A Family Doctor

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The differences were limited to diabetes encounters.

OET Writing: Step 2 - HOW TO ORGANISE YOUR CASE NOTES with Jay!

For same-day appointments, scribed and nonscribed notes did not differ in quality. Conclusions In this retrospective review, ambulatory notes were of higher quality when medical assistants acted as scribes than when physicians wrote them alone, at least for diabetes visits. Our findings may not apply to professional scribes who are not part of the clinical care team.

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As the use of medical scribes expands, additional studies should examine the impact of scribes on other aspects of care quality. Team-based models of primary care delivery may incorporate medical scribes to improve efficiency of electronic documentation.

Modifications of the medical record

Accurate documentation is important to providing high-quality patient care but can take a significant amount of time. Attending physicians have been estimated to spend as long as 52 minutes per day authoring notes. The impact of scribes on the quality of outpatient visit notes, however, is unknown.

Further information

We hypothesized that outpatient notes written by medical assistant scribes would be of similar quality to notes written by the same group of physicians without a scribe. We conducted a retrospective review of ambulatory notes from 18 primary care physicians at 8 practice sites in our health system who had adopted a care model in which medical assistants act as scribes.


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Each physician works with 2 medical assistants. To train for the new model, the physician and medical assistants participated in 2 training sessions of 2 hours each and a half day of clinic observation and evaluation with a project manager. Scribed notes were more up-to-date, thorough, useful, and comprehensible for diabetes encounters.


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  7. Of the 18 primary care physicians included in this study, none had less than one year of experience in our health system. Tenure ranged from one to 24 years with a mean of We chose diabetes encounters as examples of notes addressing chronic disease management and same-day encounters as examples of problem-focused notes because these 2 types of encounters are common in outpatient primary care practice. The items assess whether notes are up-to-date, accurate, thorough, useful, organized, comprehensible, succinct, synthesized, and internally consistent.

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    While the PDQI-9 is a validated tool, it relies on subjective ratings of note quality by the reviewer. To control for the subjective nature of the ratings, an experienced internist and an internal medicine resident coded 10 progress notes separately using the PDQI-9 and discussed the results.


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    Skip to main content. Engaged patients are more motivated to follow their care plan and have higher rates of medication adherence.

    Patients should ask their providers if they offer this option. More than 80 percent of patients opted to read their notes and, after a year, virtually all wished to continue to do so. More than 85 percent said that the availability of OpenNotes would influence whom they would choose as providers.

    Letting Patients Read the Doctor’s Notes

    The same applies to exam notes. Already overburdened physicians fear that making their notes accessible to patients will add to their workload. About 20 percent said that the way they wrote about cancer, behavioral health, substance abuse or obesity changed, and 11 percent reported taking more time writing and editing their notes.

    However, at the end of the study period, all the participating physicians opted to continue making their notes accessible to patients. In his own practice, Levy finds that sharing notes makes him more open with patients and facilitates sensitive conversations with them. The medical term for this is morbidly obese.