activeNotes: Computer-Assisted Creation of Patient Progress Notes in a Hospital Environment

We present activeNotes, a note creation prototype for use by physicians in a hospital intensive care unit. The application supports the creation of Critical Care Notes, which document the patient’s progress and prognosis. We integrate automated, context-sensitive patient data retrieval, and user control of automated data updates and alerts through the use of tags, into the note creation process, without significantly altering the interface to which physicians are accustomed. We performed a qualitative study of the prototype with 15 physicians at New York Presbyterian Hospital. Physicians found activeNotes to be valuable and said they would use it to create both formal notes for medical records and informal notes. We were surprised to find that while physicians have rejected template-based systems in the past, they expressed a desire to use activeNotes to create personalized, doctor-specific note templates to be reused with a given patient, or for a given condition.

By: Lauren Wilcox; Jie Lu; Jennifer Lai; Steve Feiner; Desmond Jordan

Published in: RC24656 in 2008


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