Using Electronic Health Record Meta-Data to Identify Variation in Trainee Progress Note Writing Patterns: Opportunity to Enhance Systems-Based Care

Abstract

Daily progress notes are the backbone of all inpatient hospitalizations. Progress notes serve as a lasting record of a patient's diagnoses, condition, and planned interventions and are essential communication tools. We designed a study to identify patterns in progress note filing and use on general surgical services. The electronic health record (EHR) data warehouse was queried for general surgical progress notes signed between July 1, 2020, and July 1, 2021. Only notes authored by resident physicians or advanced practice providers (APPs) were included, and those filed on the day of a surgery were excluded. 10 am was identified as a target for note completion as it coincided with multidisciplinary discharge rounds. Physician, case managers pharmacist, physical therapist, dietician, nurse (and collaborating disciplines) progress note views were measured using EHR access log data. A total of 8384 progress notes were analyzed; 4146 notes (49%) were authored by 81 trainees. A total of 4433 (53%) progress notes were filed before 10 am, 3673 (44%) were filed between 10 am and 6 pm, and 278 (3%) were filed after 6 pm. Variation in progress note file time was observed and associated with individual habits, residents vs APPs, day-of-week, and service structure. Surgery progress notes are viewed by collaborating disciplines throughout the workday, with high-volume viewership occurring by mid-morning. Each individual progress note received an average of 17.6 lifetime views with a range of 1 to 76. An average of 10.2 of those views occurred on the same day that the note was written. Notes that were filed after 10 am received a significantly lower number of same-day views compared to notes filed before 10am (8.4 vs 11.8, p < 0.0001). Progress notes are identified as a significant burden by trainees and even considered to contribute to duty hour violations, yet they are used regularly as a source of information for collaborating disciplines. Progress notes filed earlier are viewed more frequently. Efforts to identify barriers to timeliness may help communication and efficiency of inpatient surgical care.