Residents at various stages of training assess approximately 1,400 patients per year on our consultation-liaison service at the Mayo Clinic in Rochester, Minn. Given the variety of demands of any busy teaching service, we felt it would be helpful to reduce documentation time, while preserving adequate quality of communication via the notes, to increase the time available for education and other clinical pursuits.
To accomplish this, we created a standardized self-entry electronic consultation note that would assist in quickly documenting a thorough consultation-liaison psychiatry interview. We hypothesized that using electronic templates to type notes directly into the electronic medical record (EMR) would decrease documentation time, increase legibility, and improve the immediate availability of documentation by residents. We felt these improvements would be noted despite increasing the amount of data recorded by most residents. Further, we hypothesized that such a system would be welcomed by the residents, who valued efficiency.
To implement this system, we utilized a commercial software program, ShortHand (1). This program allows for “word expansion” wherein an entire word or phrase will appear after a keyword—often only two or three letters—is typed. More powerfully, this program allows for the creation of templates, which are customizable lists of commonly used words and phrases that are included in the final document with a simple mouse click. For example, if the user typed “ROS” into the EMR, a series of questions querying the status of the standard Review of System would appear in the form of check boxes highlighting common answers and an area allowing for free text entry to describe each of the systems. Similarly, a template outlining a thorough Mental Status Exam, including the most common descriptors of each subset thereof, would appear when the user typed “MSE,” allowing the user to click the descriptors quickly and move to the next section of the exam. The symptom lists were designed with the “Unremarkable” finding at the top of the list, and unusual results in order of descending frequency thereafter. If a resident were to omit part of an examination, a descriptor labeled “Not assessed” would be offered, allowing the resident to move to the next section of the template while reminding him or her of the expectation that this area be examined. As a commercially available program, ShortHand was designed to be compatible with many currently available software applications and works in almost any application into which you can type. This program was customized to meet the specific requirements of a psychiatric consultation note (2–4). We gave specific attention to diagnoses common on our consultation-liaison service (e.g., delirium, capacity evaluations, and affective disorders in typically complex medical patients) to permit rapid documentation. This involved the creation of templates to allow for simple point-and-click inclusion of findings, diagnoses, and recommendations most commonly seen on our service. Further, standard phrases, such as our contact information, were included automatically in all documentation, requiring no additional effort on the part of the resident. Importantly, completion of all required aspects of each particular component of the examination was mandatory prior to moving to the next screen, ensuring more thorough notes.
Residents were taught to use this note system in a 60-minute session. Note entry could be made directly into any computer workstation throughout the hospital. After training, residents were able to contact us for further clarification as questions arose. Six months after institution of this program, residents (PGY-2 through PGY-6) were asked via e-mail to estimate the time required to produce a handwritten versus an electronic note. In that same e-mail, we solicited comments regarding the use of this system compared with the traditional written note. A second copy of this e-mail was sent to the residents 3 months later to increase the response rate. This process was not reviewed by the Institutional Review Board, as our intent was to gather “quality control” data to support the use of this technology.