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#Grand Rounds

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

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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  

METHODS:

  • 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

RESULTS:

  • 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

CONCLUSION:

  • 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.

Learn More – Primary Sources:

Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior

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