Characterizing styles of clinical note production and relationship to clinical work hours among first-year residents

J Am Med Inform Assoc. 2021 Dec 28;29(1):120-127. doi: 10.1093/jamia/ocab253.


Objective: To characterize variation in clinical documentation production patterns, how this variation relates to individual resident behavior preferences, and how these choices relate to work hours.

Materials and methods: We used unsupervised machine learning with clinical note metadata for 1265 progress notes written for 279 patient encounters by 50 first-year residents on the Hospital Medicine service in 2018 to uncover distinct note-level and user-level production patterns. We examined average and 95% confidence intervals of median user daily work hours measured from audit log data for each user-level production pattern.

Results: Our analysis revealed 10 distinct note-level and 5 distinct user-level production patterns (user styles). Note production patterns varied in when writing occurred and in how dispersed writing was through the day. User styles varied in which note production pattern(s) dominated. We observed suggestive trends in work hours for different user styles: residents who preferred producing notes in dispersed sessions had higher median daily hours worked while residents who preferred producing notes in the morning or in a single uninterrupted session had lower median daily hours worked.

Discussion: These relationships suggest that note writing behaviors should be further investigated to understand what practices could be targeted to reduce documentation burden and derivative outcomes such as resident work hour violations.

Conclusion: Clinical note documentation is a time-consuming activity for physicians; we identify substantial variation in how first-year residents choose to do this work and suggestive trends between user preferences and work hours.

Keywords: EHR metadata; clinical note documentation; electronic health records; unsupervised machine learning.

MeSH terms

  • Documentation
  • Electronic Health Records
  • Humans
  • Internship and Residency*
  • Physicians*
  • Writing