ActiveNotes: Computer-assisted creation of patient progress notes

Abstract

We present activeNotes, a prototype application that supports the creation of Critical Care Notes by physicians in a hospital intensive care unit. activeNotes integrates automated, context-sensitive patient data retrieval and user control of automated data updates and alerts into the note-creation process. In a user study at New York Presbyterian Hospital, we gathered qualitative feedback on the prototype from 15 physicians. The physicians found activeNotes to be valuable and said they would use it to create both formal notes for medical records and informal notes. One surprising finding is that while physicians have rejected template-based clinical documentation systems in the past, they expressed a desire to use activeNotes to create personalized, physician-specific note templates to be reused with a given patient, or for a given condition.