Grand Rounds

Does the Electronic Health Record Match with the Actual Clinical Exam?

BACKGROUND AND PURPOSE:

ROS and PE sections in electronic health records (EHRs) are often autopopulated
Berdahl et al. (JAMA Netw Open., 2019) sought to determine how well the EHR matched with the review of systems (ROS) and physical exam (PE) documentation by emergency physicians

Case series
Participants
- Resident physicians
- 2 academic emergency departments
Study design
- Physicians were shadowed by trained observers
- 20 encounters (10 per site)
- Confirmation done by audio recordings for ROS and concurrent observation for PE
- Associated electronic health record data were subsequently reviewed
Primary outcomes
- Number of confirmed ROS systems divided by the number of documented ROS systems
- Number of confirmed PE systems divided by the number of documented PE systems

9 licensed emergency medicine residents | 180 patients
ROS
- Only 38.5% (755/1961) of documented ROS systems were confirmed
PE
- Only 53.2% (760/1429) of documented PE systems were confirmed by concurrent observation

There are considerable difference between documentation and actual performance of ROS and PE sections in the EHR
The authors suggest
- Further studies to determine extent of the problem and further state

…payers should consider removing financial incentives to generate lengthy documentation.

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