Clinical Documentation During Scribed and Non-scribed Ophthalmology Office Visits.

Purpose: Observe the impact of employing scribes on documentation efficiency in ophthalmology clinics.

Design: Single-center retrospective cohort study.

Participants: A total of 29,997 outpatient visits conducted by seven attending ophthalmologists between 1/1/2018 and 12/31/2019 were included in the study; 18,483 with a scribe present during the encounter and 11,514 without a scribe present.

Electronic health record note review in an outpatient specialty clinic: who is looking?

Note entry and review in electronic health records (EHRs) are time-consuming. While some clinics have adopted team-based models of note entry, how these models have impacted note review is unknown in outpatient specialty clinics such as ophthalmology. We hypothesized that ophthalmologists and ancillary staff review very few notes.

Methods for Large-Scale Quantitative Analysis of Scribe Impacts on Clinical Documentation.

Many medical providers employ scribes to manage electronic health record (EHR) documentation. Prior studies have shown the benefits of scribes, but no large-scale study has quantitively assessed scribe impact on documentation workflows. We propose methods that leverage EHR data for identifying scribe presence during an office visit, measuring provider documentation time, and determining how notes are edited and composed.

Electronic Health Records in Ophthalmology: Source and Method of Documentation.

Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes.

Design: EHR documentation review and analysis.

Methods: Setting: a single academic ophthalmology department.

Redundancy of Progress Notes for Serial Office Visits.

Using sequence alignment to compare more than 12,000 pairs of progress notes, we find that progress notes were, on average, 74.5% redundant with the prior progress note written for the same patient.