Electronic health record systems in ophthalmology: impact on clinical documentation.

ABSTRACT:

Objective

To evaluate quantitative and qualitative differences in documentation of the ophthalmic examination between paper and electronic health record (EHR) systems.

Design

Comparative case series.

Participants

One hundred fifty consecutive pairs of matched paper and EHR notes, documented by 3 attending ophthalmologist providers.

Methods

An academic ophthalmology department implemented an EHR system in 2006. Database queries were performed to identify cases in which the same problems were documented by the same provider on different dates, using paper versus EHR methods. This was done for 50 consecutive pairs of examinations in 3 different diseases: age-related macular degeneration (AMD), glaucoma, and pigmented choroidal lesions (PCLs). Quantitative measures

SUBMITTER: Sanders DS 

PROVIDER: S-EPMC12329761 | biostudies-literature | 2013 Sep

REPOSITORIES: biostudies-literature