Background and objective The clinical note documents the clinician's information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes.Materials and methods A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes.Results The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval.Conclusions The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

Background and objectiveThe outpatient clinical note documents the clinician's information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole.Materials and methodsRetrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ.ResultsThe overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04).ConclusionsWe found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.

Background and Objectives: The transition to clerkships is one of the most challenging times during medical school. To help students better cope, many schools have established transition-to-clerkship curricula. Such curricula may optimally prepare students through increasing their self-efficacy and response efficacy. We hypothesized that a small-group, near-peer-led format would be ideally suited to help students achieve these outcomes. Methods: During process improvement for a transition-to-clerkship curriculum, we conducted an informal focus group and subsequent survey of postclerkship students to guide curricular innovation, including incorporation of third- and fourth-year students as near-peer instructors in a seminar format. Seminars included three sequential small-group discussions focused on discrete topic areas and concluded with a large-group session highlighting salient discussion points. To evaluate the impact of this educational strategy, near-peer learners were surveyed before and after the seminars. Results: Junior student participants reported feeling more prepared to integrate into the health care team, develop a clerkship study plan, and access applicable, valuable study materials, both immediately following the seminars and 6 months later, demonstrating increased self-efficacy. These students placed equal or greater value on these topics as compared to students in previous year groups, demonstrating similar response efficacy. Conclusions: This study demonstrated an increase in student self-efficacy that persisted 6 months postintervention, in addition to similar response efficacy. Future research could be directed toward: (1) investigating whether improvements in self-efficacy among students transitioning to clerkships are associated with improved clerkship performance and (2) studying outcomes for near-peer teachers.

Having a mentor is associated with positive job satisfaction among Navy family physicians, even after adjusting for multiple other factors. An implication is that a mentorship program may be a strategy for improving job satisfaction.

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