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Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record

Yadav, S. et al. Journal of the American Medical Informatics Association 24: 140-144,(2016).

OVERVIEW

This study compares the accuracy of physical examination findings documentation between paper and electronic records in initial progress notes.

METHODS

Initial progress notes from patients admitted to hospital between August 2011 and August 2013 were retrospectively reviewed. These patients had 5 specific diagnoses with invariable physical findings: permanent atrial fibrillation, aortic stenosis, intubation, lower limb amputation, and cerebrovascular accident (CVA) with hemiparesis. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm.

KEY FEATURES

Inaccuracies were found to be more prevalent in EHRs than in a paper system and omissions more prevalent in the paper system. 

  • Physical exam findings were more likely to be inaccurately recorded in an EHR system (24% vs 4.4%), but were more likely to be omitted in a paper system (41.2% vs 17.6%).
  • Resident physician documentation was more accurate than attending physician documentations, regardless of the mode of documentation.
  • Notes were written earlier in the workday in the paper system.
  • Overall accuracy of documentation was low (54.4% and 58.4% accurately documented physical exam findings in the paper system and EHR respectively).

BOTTOM LINE

As EHRs become more disseminated, research should focus on implementing training programs and incentives that support accurate documentation.

COMMENTARY

A good study looking at the outcomes of switching to an EHR from a paper system. The increase in inaccuracies vs. omissions signals a need to train students and residents in a way that supports EHR specific accuracy in documentation i.e. reducing reliance on copy-paste function that propagates errors; using checklists and templates rationally; etc. However, this article gives no guidance as to how this can be done.