HEALTHY LIVING

Doctor Note-Taking Style Could Affect Patient Care: Study

05/25/2012 02:57 am ET

The way your doctor takes notes could affect the way he or she cares for you, a new study suggests.

Research published in the Journal of the American Medical Informatics Association shows that doctors who take patient notes by dictating them give lower quality of care to their patients, compared with doctors who take notes via "structured documentation."

Structured documentation is when the notes are taken and separated by section (like "family history" or "present illness"). Dictating is defined as reading information over a phone, which is then transcribed to an electronic record.

"Dictating may be easier for the doctor, but patients need to be careful," study researcher Dr. Jeffrey Linder, M.D., associate professor of medicine at Brigham and Women's Hospital and Harvard Medical School, said in a statement. "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."

The study included 18,569 visits by 7,000 people. People in the study had diabetes and/or coronary artery disease.

Among the 234 doctors who saw these patients, 9 percent of them dictated their notes, 29 percent of them took notes using structured documentation, and 62 percent typed "free-text" notes (where there's just one window to type down information, a la free note-taking).

Thirty days after the visits, the researchers looked at how the patients were cared for with 15 different measures.

They found that care quality was worse for patients whose doctors dictated the notes, particularly in the areas of documenting patient use of tobacco, diabetic eye exams and antiplatelet medication.

Just last year, a study was published in the journal Annals of Internal Medicine showing that 90 percent of people want to know what their doctors wrote in their patient charts, TIME reported.

However, the study also showed that more than half of doctors surveyed wouldn't want to make their notes available for patients to view electronically for one year, according to TIME.

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