• Sharon Mulvehill, Gregory Schneider, Cassie Murphy Cullen, Shelley Roaten, Barbara Foster, and Anne Porter.
• UTS Family Medicine Residency Program, Department of Family Medicine, the University of Texas Southwestern Medical Center at Dallas, 6303 Harry Hines Boulevard, Dallas, TX 75390-9165, USA. smulve@parknet.pmh.org
• J Am Board Fam Pract. 2005 Nov 1; 18 (6): 464-9.

PurposeTo compare a template-driven medical documentation system to undirected handwritten documentation and determine whether the template (1) decreases physician evaluation time, (2) increases gross billing, and (3) increases physician satisfaction with the documentation process.MethodsA prospective randomized trial of documentation with a template system (T-System for Primary Care, Dallas, TX) versus undirected handwritten documentation was conducted in 2 separate teams of a single family medicine residency program. After training, one team used the template system and the other team used undirected written documentation. Clinic visit duration was recorded. Medical records were evaluated by a blinded professional coder to assign an evaluation/management code. Clinic visit duration and coding level differences were evaluated using an independent t test. At the conclusion of the study, residents completed a questionnaire to determine physician satisfaction with the documentation tool. Survey responses were on a -2 to + 2 Likert scale. Means and standard deviations are reported.ResultsA total of 1339 patients were included in the analysis of patient visits. There was no significant difference in clinic time between the template system and the written documentation visits. The mean visit time was 1.75 hours for both teams. For the analysis of gross billing, 1237 charts were included. The mean billing amount for written documentation was USD $150 and for the template system it was USD $163--a statistically significant difference. The physicians' surveys favored continuing to use the template documentation method.ConclusionsThe template medical documentation system compared with undirected written documentation produced a significantly higher bill for the visit, yielding no differences in evaluation time, and was overall positively received by the residents and faculty.

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