• M Apkon and P Singhaviranon.
• Pediatrics and Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT 06520-8064, USA. Michael.apkon@yale.edu
• Intensive Care Med. 2001 Jan 1;27(1):122-30.

ObjectiveTo test the hypotheses that: (1) integrating information processing tasks using an electronic clinical information system (ECIS) decreases time to complete these tasks by hand; and (2) structured data entry encourages generation of more detailed records and capture of specific data elements even when entry is voluntary.DesignProspective observational time analysis during medical documentation tasks. Retrospective analysis of clinical documentation completed by hand or electronically.SettingEleven bed pediatric intensive care unit within an academic medical center.ParticipantsFive pediatric intensive care medicine attending physicians.MeasurementsCompared handwritten and electronic documentation to determine: (1) time spent entering data or composing notes; (2) number of descriptors documenting patients' physical exams; (3) users' preferences for structured or unstructured data entry; (4) frequency of documenting specific data elements related to nutritional support.ResultsDocumentation time varied by user but not charting method: it took 13 % less time to document using the ECIS but this was not significant. Electronic documents were more detailed than handwritten containing 50 % more descriptors (17.8 +/- 1.4 vs 11.6 +/- 1.4) overall and some data elements that were not handwritten: information related to nutritional supplementation was recorded in 13 % of electronic documents but in none of 89 handwritten documents.ConclusionsElectronic and handwritten documentation consumed equal amounts of time. Structured entry, compared to handwriting, may encourage recording of specific or otherwise unincorporated data elements resulting in a more detailed record. This suggests that user interfaces and decision support components may influence both the types and complexity of clinical data recorded by caregivers.

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