Rana Alissa
University of Florida Jacksonville, USA
Scientific Tracks Abstracts: Gen Med (Los Angeles)
Objectives: Whether optimizing physicians notes save time for patient care, improve providers satisfaction and patient safety. Methods: 4 note types were optimized in our Mother-Baby Unit (MBU): History and Physical (H&P), Discharge (DC) summary, progress notes (PN), and hand-off list. Free text elements documented elsewhere in medical records (e.g. delivery information, maternal data, lab result...) were identified and replaced with dynamic “Smart Links” that populate portions of the note. Remaining free text elements that could be replaced with “Smart Lists” were identified. The new note templates (NT) were given new smart links to improve accessibility. 9373 infants admitted to MBU between 1/2016-9/2019. Average Length of Stay (LOS) was 2 days. Every infant averages 4 notes: H&P, PN, DC summary and hand-off. New and old NT was completed for same infant by 10 residents. Actions taken (clicks, keystrokes, transitions and mouse-Keyboard switches) were documented. Survey was sent to providers regarding satisfaction. Incident reporting was tracked. Results: 69 actions were saved when comparing the new and old NT completion. H&P: 11, PN: 8, D/C summary: 18, Handoff: 32. Time spent was documented in seconds. The new NT took shorter time. Time saved was divided by the number of actions saved: 20 seconds saved per action. Discussion: Introducing electronic health records into health care intended to improve patient care and organizational efficiency. However, not optimized NT require spending longer hours behind computers, shorter time with patients, suboptimal patient safety, providers dissatisfaction and physicians burnout. Conclusion: Optimizing physician’s notes saved time, improved providers satisfaction and patient safety.
Rana Alissa has completed her MD at the age of 24 years from Damascus University and pediatrics residency from University of Florida (UF) College of Medicine Jacksonville. She is an assistant professor in the pediatric department, division of neonatology. She is a third year fellow in Medical Informatics at UF. She published 8 papers majority about the health of newborns. She loves teaching and she earned numerous teaching awards. She created 43-page guide book for resident survival in the newborn nursery. She brought the oral glucose gel and donor milk to the newborn nursery which helped increasing breastfeeding rates 3-folds.
