Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs.

ABSTRACT:

Background

Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality.

Methods

Patients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI

SUBMITTER: Weiner M 

PROVIDER: S-EPMC11264844 | biostudies-literature | 2024 Jul

REPOSITORIES: biostudies-literature