Concordance Between Electronic Clinical Documentation and Physicians' Observed Behavior.

ABSTRACT:

Importance

Following the adoption of electronic health records into a regulatory environment designed for paper records, there has been little investigation into the accuracy of physician documentation.

Objective

To quantify the percentage of emergency physician documentation of the review of systems (ROS) and physical examination (PE) that observers can confirm.

Design, setting, and participants

This case series took place at emergency departments in 2 academic medical centers between 2016 and 2018. Participants' patient encounters were observed to compare real-time performance with clinical documentation.

Exposures

Resident physicians were shadowed by trained observers for 20 encounters (10 encounters per physician per site) to obtain real-time observational

SUBMITTER: Berdahl CT 

PROVIDER: S-EPMC6751766 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature