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DOI: 10.1177/1062860612445307
2013 28: 25 originally published online 8 June 2012 American Journal of Medical Quality
George J. Kargul, Scott M. Wright, Amy M. Knight, Mary T. McNichol and Jeffrey M. Riggio
Documentation and Improve Provider Efficiency
The Hybrid Progress Note: Semiautomating Daily Progress Notes to Achieve High-Quality

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American Journal of Medical Quality
28(1) 25 32
2013 by the American College of
Medical Quality
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DOI: 10.1177/1062860612445307
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Article
Traditional paper medical records are thought to be sub-
optimal from a patient care and safety perspective when
compared with electronic records. Electronic records are
thought to be superior to paper because information is
better organized, legible, and more easily retrieved.
1
For
these reasons, the development of electronic health
records (EHRs), including provider documentation, is a
national priority set by the American Recovery and Rein-
vestment Act of 2009.
2
It also is hoped that EHRs will
save money, improve quality of care, decrease the
number of medical errors, improve provider efficiency,
and improve the exchange of data among health care
providers.
1,3
Although many hospitals have some form of elec-
tronic medical records (EMRs), physicians are generating
electronic notes in only 12% of US hospitals.
4
The 2 main
barriers to the implementation of more complete EMRs
and going completely paperless are costs (particularly
hardware, software, and technical support) and physician
resistance.
4-6
Another more contemporary obstacle to
going paperless is the recognition that many of the cur-
rent iterations of electronic progress notes allow copy and
paste or have a carry forward feature (which essentially
copies and pastes content from the last note), thereby
threatening the validity of the note.
7,8
Until these barriers
are overcome, optimizing the quality of paper documen-
tation is essential to meet quality and safety goals.
In an effort to improve the quality of documentation
and decrease the workload associated with daily docu-
mentation of progress notes on an inpatient medical
445307AJMXXX10.1177/1062860612445307Am
erican Journal of Medical QualityKargul et al
Kargul et al
1
Johns Hopkins Bayview Medical Center, Baltimore, MD
2
Thomas Jefferson University Hospitals, Philadelphia, PA
3
Thomas Jefferson University, Philadelphia, PA
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article. The authors
disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Dr Wright is supported
as a Miller-Coulson Family Scholar through the Hopkins Center for
Innovative Medicine.
Corresponding Author:
Jeffrey M. Riggio, MD, MS, Division of Hospital Medicine, Department
of Medicine, Thomas Jefferson University, 833 Chestnut Street,
Suite #600, Philadelphia, PA 19107
Email: Jeff.Riggio@jefferson.edu
The Hybrid Progress Note:
Semiautomating Daily Progress
Notes to Achieve High-Quality
Documentation and Improve
Provider Efficiency
George J. Kargul, MD, MS,
1
Scott M. Wright, MD,
1
Amy M. Knight, MD,
1

Mary T. McNichol, MS,
2
and Jeffrey M. Riggio, MD, MS
3

Abstract
Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved
documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation.
Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of
documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is
prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5% and 60%
to 100% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3%
to 0% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest
that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves
documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming
electronic progress note.
Keywords
quality care, electronic medical records, progress notes, documentation, standardization
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26 American Journal of Medical Quality 28(1)
service, the authors developed a paper note template that
is automatically populated with pertinent objective data
contained in the central patient database (eg, vital signs,
active medications). Each note is, therefore, individual-
ized with data specific to each patient. The provider is
then left with space to handwrite additional findings and
data and to document his or her thoughts, including medi-
cal decision making. This note was called a hybrid prog-
ress note because it is a semiautomated paper note. Such a
semiautomated format not only standardizes much of the
note content, but it also can (1) be customized to include
prompts to promote patient safety and quality care,
(2) make the work of documentation more efficient by
decreasing time spent securing patient data and writing it
down, and (3) serve as a model and/or bridge for the forth-
coming electronic note. The authors hypothesized that the
hybrid note would improve documentation quality; their
experience during developing and rolling out the hybrid
progress note (along with the safety and quality enhancing
features that were purposely incorporated) is described.
Context, Product, and Rollout
Setting
The authors implemented and studied the use of the
hybrid note at Thomas Jefferson University Hospitals, a
957-bed academic medical center in Philadelphia,
Pennsylvania comprising 3 divisions (main, Jefferson
Hospital for Neurosciences [JHN], and Methodist
Hospital). The main hospital and JHN are in Center City
Philadelphia. In 2001-2005 the main hospital and JHN
started using General Electrics Centricity Enterprise
(General Electric Company, Fairfield, CT), an evolving
EMR with a central database containing objective data,
computerized physician order entry, and flow sheet
charting. However, electronic physician progress notes
have yet to be included in the EMR. The hybrid progress
notes have been in use at these 2 divisions since 2005.
The Methodist Hospital division is a 198-bed hospital
located in a community setting in South Philadelphia.
This hospital transitioned to General Electrics Centricity
Enterprise with results (radiology, labs, vitals, medica-
tions) in January 2011 and to computerized physician
order entry in June 2011. Hybrid progress notes became
available in April 2011.
Hybrid Progress Note Development,
Design, and Functionality
The data to be included in the hybrid note were purposely
and thoughtfully selected. The key planning elements in
developing the hybrid progress note included the follow-
ing: (1) reviewing what data elements were available for
potential incorporation, (2) deciding which variables add
value to the note, (3) determining the source from which
to extract the selected data, and (4) selecting the format-
ting and style that would support both the notes con-
struction and readability. Using a modified Delphi
approach, many interns, residents, and attending physi-
cians from multiple specialties were consulted for their
input on each of these points. After focus group meetings
with these stakeholders, clinical leaders and members of
the study team formed a core group that met regularly to
design and iteratively revise the template. In collabora-
tion with information technology personnel, functions
were created that would pull patient data from the central
database and produce the formatted document: the hybrid
progress note (Figure 1).
The prepopulated data in the hybrid note includes
active medications; vital signs (maximum, minimum, and
current); inputs, outputs, and fluid balance (intravenous
[IV] fluid, by mouth [PO], stools, and urine); and blood
glucose levels. Rather than documenting only the most
current vital signs, the authors chose to include the maxi-
mum and minimum values for each vital sign during the
previous 24 hours, so that providers are encouraged to
reflect more deeply on the patients health status, stability,
and progress. It was decided to push the inputs/outputs
into the hybrid notes, along with the additional specificity
of input (eg, IV, PO) and output types (gastrointestinal or
urine), thereby enabling medical decision making at the
point of care with regard to volume status.
Horizontal lines are printed where providers write
their thoughts and findings. A field to write the date and
time is provided to distinguish the time the note was writ-
ten from the time when the template was generated. An
area at the bottom is reserved for the attending physician
to document. This feature ensures that the attending note
accompanies the house staff note on the same page,
thereby facilitating appropriate supervision of the docu-
mentation generated by house staff and/or medical stu-
dents. Additional features that have been incorporated
more recently include deep vein thrombosis (DVT) pro-
phylaxis documentation and an area to document indwell-
ing catheters (Figure 1).
With respect to implementation, the hybrid notes are
generated via a batch program to designated printers on
the nursing units. The eligible printers are duplex enabled
(to minimize paper consumption) and are strategically
placed around the facility for provider convenience. The
notes for the main and JHN divisions are collated by
patient care teams, and a house officer will use those notes
for rounds. In the Methodist Hospital division, the nursing
staff place the notes directly on the charts each morning.
Adoption
The hybrid note was instituted at the main hospital and
JHN divisions in 2005. The initial users were mainly
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Kargul et al 27
(continued)
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28 American Journal of Medical Quality 28(1)
Figure 1. The hybrid progress note: front portion with active medications; vital signs (maximum, minimum, and current); inputs,
outputs, and fluid balance (intravenous fluids, by mouth, stools, and urine); and blood glucose levels; back portion with lines/
catheters, deep vein thrombosis (DVT) prophylaxis, and attending physician comments area
Figure 1. (continued)
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Kargul et al 29
internal medicine residents. Hospital-wide use soon fol-
lowed once providers learned of the resource and how to
generate their own notes. It was implemented at the
Methodist Hospital division in April 2011 after the avail-
ability of results in the EMR.
When designing new systems, barriers must be antici-
pated and errors must be explored during pilot testing, so
users may be given appropriate guidance about ways to
avoid potentially dangerous pitfalls. Examples of 2 such
issues that physicians were encouraged to consider and
reflect on during the rollout are described here.
1. Users of the hybrid note will have all the notes
for their patients at once and carry them while
rounding and documenting. Therefore, care
must be taken to avoid writing on the wrong
template or placing a note in the wrong chart.
2. Until the note is safely in the patients chart,
care must be taken to protect patient informa-
tion. A hybrid note is a medical document and
must be protected under the same guidelines
set forth in the Health Insurance Portability and
Accountability Act.
9
Method of Evaluation
To objectively evaluate the hybrid notes impact, a chart
review was conducted at the Methodist Hospital division
that compared daily progress notes before and after the
implementation of the hybrid note.
For comparison, daily progress notes were selected
from 110 charts in May of 2010 (before hybrid note
implementation) and 110 charts in May of 2011 (after
hybrid note implementation). All charts were from the
nonintensive care unit medicine services and had an
admission start date during the month of May and a total
length of stay of at least 3 days. Of these eligible charts,
110 from each time period were randomly selected, and
the progress note of the second hospital day was reviewed.
This project was approved by the Thomas Jefferson
University human research board.
In reviewing the 220 charts, data were collected
regarding frequency of hybrid note use, author (house
staff vs nonhouse staff), and whether specific pieces of
data were documented (including current vital signs, vital
signs range, glucose levels for patients with diabetes,
labs, physical exam findings, current medications, and
DVT prophylaxis). The number of unapproved abbrevia-
tions and the number of words written in the assessment/
plan also were counted as part of this chart audit.
Various metrics were compared before and after
hybrid note implementation using the Fisher exact test
and t test to determine the aggregate mean differences.
All statistical analyses were conducted using SPSS v15.0
statistical software application (SPSS Inc, an IBM com-
pany, Chicago, IL).
In an attempt to estimate the potential time savings
associated with the use of hybrid notes, we followed the
house staff from several medicine teams before the
hybrid note was originally implemented at Thomas
Jefferson University Hospitals and recorded the amount
of time spent writing portions of their note in a tradi-
tional format.
To assess satisfaction with this resource, the authors
interviewed 2 senior clinician leaders: the internal medi-
cine residency director (pulmonary critical care attending
and consultant) and the medication safety officer (clinical
pharmacist). These leaders were chosen because they are
integrally involved with matters related to health care
processes and quality outcomes within the delivery sys-
tem. All authors carefully reviewed their perspectives,
came to consensus on the recurrent themes, and together
selected the quotations that most comprehensively cap-
tured their ideas.
Results
After implementation at the Methodist Hospital division,
the hybrid note was used 100% of the time (Table 1).
Being a hospital in a community setting, roughly three
quarters of the notes were completed by community-
based attendings only, without house staff involvement.
Notes created using the hybrid note template have sub-
stantively more documentation of objective data, fewer
unapproved abbreviations in the medication list (when it
was present), and longer assessments and plans. Although
current vital signs and active medications were included
in less than 76% of the notes in the prehybrid selection,
these data points are prepopulated in the hybrid note and
therefore are included 100% of the time in the hybrid
note selection (P < .001). Other areas of improvement
with use of the hybrid note are documentation of glucose
levels in patients with diabetes and the handwritten
assessment and plan section. At the same time, using the
hybrid note improved documentation of current labs,
which were not prepopulated in the hybrid note, and the
use of unapproved abbreviations in the medication list
decreased. There was no statistically significant differ-
ence in either authorship (house staff or nonhouse staff)
or unapproved abbreviations outside the medication list.
The residency program director reported that house
staff, fellows, and staff attendings remain highly satisfied
with this form of computer-assisted documentation. He
stated that house staff and fellows are better able to
review objective data, reconcile medications daily, and
produce higher-quality notes in less time. He believes
that house staff are better prepared for morning rounds
and that rounding is now more comprehensive and
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30 American Journal of Medical Quality 28(1)
efficient. His residents and fellows also have reported
that daily notes are of a higher quality (in terms of content
and legibility), have provided them with a better under-
standing of patients clinical status and plan, and that they
prefer hybrid notes to unstructured paper charting.
Finally, he stated his preference for this modality, citing
that the hybrid note is perfectly positioned to take advan-
tage of information technology in medical documenta-
tion, while avoiding the pitfalls of the copy-and-paste
problem seen with electronic documentation (G. C.
Kane, oral communication, April 2011).
Interviews with the medication safety officer revealed
that chart audits have fewer quality issues than before the
hybrid notes were used, citing fewer unapproved abbre-
viations. He also felt that the hybrid note facilitates better
evaluation of medications when transferring patients
between levels of care (C. Senholzi, oral communication,
April 2011).
The authors observed that it took an average of 5 min-
utes per patient note to transcribe the medication list and
most recent vital signs.
Discussion
The hybrid progress note is a semiautomated, standard-
ized paper template that promotes patient safety and
quality of care by ensuring that key components of daily
patient evaluation are documented and that patient safety
standards of documentation are met. In adhering to regu-
lations,
10
the hybrid note can help reduce the use of dan-
gerous unapproved abbreviations in the medication list. It
improves efficiency and workflow by eliminating the
need to secure and scribe the medication list and much of
the objective data into the note. We believe that this effi-
ciency dividend translates into more thoughtful docu-
mentation because we also see that labs are more
commonly incorporated into notes (which is not an auto-
matic feature of the hybrid note) and that assessments/
plans are longer when the hybrid note is used. Disease-
specific conditions also are enhanced, with more diabetes
patients having the most recent glucose values docu-
mented in the note. If the hybrid note can improve pro-
viders documentation habits, it may likewise improve
patient care. We hope that residents and interns find more
time for educational activities (which is especially
important for our busy house staff, who are constrained
by duty-hour restrictions).
11,12
Supervision is promoted
by ensuring that attending documentation accompanies
resident and medical student notes on the same page,
facilitating review of the content and rationale recorded
by the trainee. Improving the workflow and efficiency of
morning rounds also likely supports better supervision
and education. Finally, some have felt that a written
assessment and plan (medical decision making) is supe-
rior to an electronic document because it obviates the
problem of the copy or forward of information from prior
documents, thereby prompting students and house offi-
cers to rethink their judgments daily.
7,8,13
Other computer-assisted documentation projects have
been described. Rosenblooms team developed a computer-
assisted documentation instrument that they called the
Clinical Note Capture Tool. This tool retrieves objective
data from the centralized patient database and embeds it
into an electronic, rather than paper, template.
14

Jernigan and Lester
15
also described a printable semiauto-
mated electronic template. Both these tools require the
Table 1. Characteristics of Daily Progress Notes Before and After the Implementation of the Hybrid Note
Note Characteristic
PreHybrid Note
(n = 110)
PostHybrid
Note (n = 110) P Value
Use of hybrid note, n (%) NA 110 (100)
House staff author, n (%) 27 (24.5) 28 (25.5) .87
Attending only author, n (%) 83 (75.5) 82 (74.5)
Objective data documented
Current vitals, n (%) 83 (75.5) 110 (100) <.001
Vitals ranges, n (%) 16 (14.5) 110 (100) <.001
Glucose levels/diabetes patients, n (%) 4/30 (13.3) 33/33 (100) <.001
Labs, n (%) 74 (67.3) 89 (80.9) .02
Physical exam, n (%) 110 (100) 110 (100) 1
Medications documented, n (%) 66 (60) 110 (100) <.001
Unapproved abbreviations
Medication list, n (%) 15 (13.6) 0 (0) <.001
Elsewhere throughout note, n (%) 6 (5.5) 6 (5.5) 1
DVT prophylaxis documented, n (%) 47 (42.7) 96 (87.3) <.001
Average words in assessment/plan 19.4 29.5 <.001
Abbreviation: DVT, deep vein thrombosis.
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Kargul et al 31
user to create the note entirely using a keyboard and
mouse, conforming to what Embi et al
16
referred to as
computerized physician documentation. Rather than store
the information electronically, however, these tools
intend that the user prints out the final document and
places it on the paper chart.
14-16
In contrast, users of our
hybrid note scribe their input on the semiautomated paper
template, freeing them from the keyboard to document as
they round. Although our goal is to transition to a paper-
less system, being able to document on the fly seems to fit
better into our providers workflow and may be why our
hybrid note has been so popular. Understanding physi-
cian workflow needs is an important lessoned learned
as we proceed with planning our future electronic
documentation.
The hybrid progress note appears to be a success at our
institution, but we continue to look for ways to add value
or improve documentation behavior. Low-tech solutions
to changing documentation behavior can be effective. At
one community hospital, for example, pharmacists
reported using stickers on daily progress notes to alert
providers to DVT risk factors and make recommenda-
tions.
17
Because the template can be easily modified,
similar interventions can be incorporated into progress
notes algorithmically. For example, fields to document
indwelling catheters and DVT prophylaxis were added to
the template well after the initial rollout to better comply
with more recent Patient Safety Authority objectives.
18

This project has inspired us to think about ways in which
we can directly empower pharmacists (or other ancillary
services) to electronically embed their signed recommen-
dations or suggestions into the hybrid note in a manner
that might advance deeper reflection, positively affect the
care plan, and improve documentation behavior.
EMR development is well described and dates back to
the 1960s.
19,20
Many hospitals are now in transition from
paper to paperless medical records systems, and this evo-
lution often takes a long time and involves a modular and
stepwise process.
15,21-24
Jernigan and Lester
15
illustrated
this point when they described their tool as a bridge, or
intermediary step, in developing electronic notes. We feel
that the hybrid note, too, can be thought of as a stepping
stone toward full electronic documentation, mainly
because we intend to design an electronic note in its form
and also because it has given our stakeholders valuable
experience in the development process. Furthermore, the
barriers to implementing a comprehensive EMR are
many, and successful change management strategies
require smooth transitions that put the focus on the people
expected to change.
5,6,25
We have put the focus on our
providers by improving their workflow, making this tool
very popular. By overcoming the barrier of physician
resistance to change, we anticipate that the transition to
electronic documentation will proceed more smoothly.
Furthermore, developing this tool has inspired a sense of
trust and a culture of innovation among the collaborators,
and we foresee that this will translate into further suc-
cesses as we proceed with developing a paperless
system.
The limitations of this report should be considered.
First, the estimations of time savings are based on obser-
vations of a limited number of providers. However, the
estimations were made very conservatively. Second, we
did not evaluate the time needed to secure hybrid notes.
Occasional obstacles include printers running out of
paper and other related printer maintenance issues.
Finally, the data from the chart audit relate to documenta-
tion practices; however, we cannot be certain that the pro-
viders behaviors in patient care practices were fully
concordant with what they wrote.
Conclusion
Thoughtful informatics initiatives have the power to
enhance quality.
26
Although institutional culture is often
a barrier to change, improving provider workflow can be
the carrot that overcomes this resistance. Creating semi-
automated daily progress notes that are formatted to
facilitate reflection on patient care while improving pro-
vider workflow has been a successful initiative and has
translated into higher-quality documentation.
Acknowledgments
We thank Andrea Bolden, Kristen Keener, and Lili Tang, MS,
for editorial reviews. We also thank Gregory Kane, MD, and
Craig Senholzi, RPh, MBA, for participating in the interviews.
Finally, we thank the Thomas Jefferson University Hospitals
Informatics Systems staff, in particular Michael Ekshtut,
Richard Beatty, and Kevin Daly, MBA.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Dr Wright is supported as a Miller-Coulson Family Scholar
through the Hopkins Center for Innovative Medicine.
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