RT Journal Article
SR Electronic
T1 Template-Guided Versus Undirected Written Medical Documentation: A Prospective, Randomized Trial in a Family Medicine Residency Clinic
JF The Journal of the American Board of Family Practice
JO J Am Board Fam Med
FD American Board of Family Medicine
SP 464
OP 469
DO 10.3122/jabfm.18.6.464
VO 18
IS 6
A1 Sharon Mulvehill
A1 Gregory Schneider
A1 Cassie Murphy Cullen
A1 Shelley Roaten
A1 Barbara Foster
A1 Anne Porter
YR 2005
UL http://www.jabfm.org/content/18/6/464.abstract
AB Purpose: To compare a template-driven medical documentation system to undirected handwritten documentation and determine whether the template (1) decreases physician evaluation time, (2) increases gross billing, and (3) increases physician satisfaction with the documentation process.Methods: A prospective randomized trial of documentation with a template system (T-System for Primary Care, Dallas, TX) versus undirected handwritten documentation was conducted in 2 separate teams of a single family medicine residency program. After training, one team used the template system and the other team used undirected written documentation. Clinic visit duration was recorded. Medical records were evaluated by a blinded professional coder to assign an evaluation/management code. Clinic visit duration and coding level differences were evaluated using an independent t test. At the conclusion of the study, residents completed a questionnaire to determine physician satisfaction with the documentation tool. Survey responses were on a −2 to + 2 Likert scale. Means and standard deviations are reported.Results: A total of 1339 patients were included in the analysis of patient visits. There was no significant difference in clinic time between the template system and the written documentation visits. The mean visit time was 1.75 hours for both teams. For the analysis of gross billing, 1237 charts were included. The mean billing amount for written documentation was $150 and for the template system it was $163—a statistically significant difference. The physicians’ surveys favored continuing to use the template documentation method.Conclusions: The template medical documentation system compared with undirected written documentation produced a significantly higher bill for the visit, yielding no differences in evaluation time, and was overall positively received by the residents and faculty.