Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record

Yadav, Siddhartha; Kazanji, Noora; C, Narayan K.; Paudel, Sudarshan; Falatko, John; Shoichet, Sandor; Maddens, Michael; Barnes, Michael A.

doi:10.1093/jamia/ocw067

Cited by 46 publications

(40 citation statements)

References 29 publications

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“…Previous investigators have researched nurse documentation accuracy, 11 compared accuracy of paper with electronic health records, 12,13 and analyzed accuracy of physician documentation of discrete fields, such as diagnoses. 14,15 However, to our knowledge, no other study has attempted to quantify the accuracy of electronic physician documentation using concurrent observation.…”

Section: Discussionmentioning

confidence: 99%

Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior

et al. 2019

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Key PointsQuestionHow closely does documentation in electronic health records match the review of systems and physical examination performed by emergency physicians?FindingsIn this case series of 9 licensed emergency physician trainees and 12 observers of 180 patient encounters, 38.5% of the review of systems groups and 53.2% of the physical examination systems documented in the electronic health record were corroborated by direct audiovisual or reviewed audio observation.MeaningThese findings raise the possibility that some physician documentation may not accurately represent actions taken, but further research is needed to assess this in more detail.

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Section: Discussionmentioning

confidence: 99%

Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior

et al. 2019

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“…[2][3][4][5][6][7][8] Overburdened practitioners may import inaccurate medication lists, propagate other erroneous information electronically by copying and pasting older parts of the record, or enter erroneous examination findings. 2,8,9 EHRs may also lack critical information (errors of omission) because of limited interoperability among health care sites. 10 Among primary care physicians sharing notes with patients, 26% anticipated that patients would find nontrivial errors.…”

Section: Introductionmentioning

confidence: 99%

Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes

et al. 2020

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IMPORTANCE As health information transparency increases, patients more often seek their health data. More than 44 million patients in the US can now readily access their ambulatory visit notes online, and the practice is increasing abroad. Few studies have assessed documentation errors that patients identify in their notes and how these may inform patient engagement and safety strategies. OBJECTIVE To assess the frequency and types of errors identified by patients who read open ambulatory visit notes. DESIGN, SETTING, AND PARTICIPANTS In this survey study, a total of 136 815 patients at 3 US health care organizations with open notes, including 79 academic and community ambulatory care practices, received invitations to an online survey from June 5 to October 20, 2017. Patients who had at least 1 ambulatory note and had logged onto the portal at least once in the past 12 months were included. Data analysis was performed from July 3, 2018, to April 27, 2020. EXPOSURES Access to ambulatory care open notes through patient portals for up to 7 years (2010-2017). MAIN OUTCOMES AND MEASURES Proportion of patients reporting a mistake and how serious they perceived the mistake to be, factors associated with finding errors characterized by patients as serious, and categories of patient-reported errors. RESULTS Of 136 815 patients who received survey invitations, 29 656 (21.7%) responded and 22 889 patients (mean [SD] age, 55.16 [15.96] years; 14 447 [63.1%] female; 18 301 [80.0%] white) read 1 or more notes in the past 12 months and completed error questions. Of these patients, 4830 (21.1%) reported a perceived mistake and 2043 (42.3%) reported that the mistake was serious

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“…different information when presented a case on a paper chart versus on a hybrid paper/electronic chart. Additionally, physicians documented different physical examination findings in a paper-based record than in an electronic health record [54]. Skills such as safe prescribing and the diagnostic process can be partially taught in a context-independent manner [55,56].…”

Section: Plos Onementioning

confidence: 99%

Electronic charts do not facilitate the recognition of patient hazards by advanced medical students: A randomized controlled study

et al. 2020

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Chart review is an important tool to identify patient hazards. Most advanced medical students perform poorly during chart review but can learn how to identify patient hazards context-independently. Many hospitals have implemented electronic health records, which enhance patient safety but also pose challenges. We investigated whether electronic charts impair advanced medical students' recognition of patient hazards compared with traditional paper charts. Fifth-year medical students were randomized into two equal groups. Both groups attended a lecture on patient hazards and a training session on handling electronic health records. One group reviewed an electronic chart with 12 standardized patient hazards and then reviewed another case in a paper chart; the other group reviewed the charts in reverse order. The two case scenarios (diabetes and gastrointestinal bleeding) were used as the first and second case equally often. After each case, the students were briefed about the patient safety hazards. In total, 78.5% of the students handed in their notes for evaluation. Two blinded raters independently assessed the number of patient hazards addressed in the students' notes. For the diabetes case, the students identified a median of 4.0 hazards [25%-75% quantiles (Q25-Q75): 2.0-5.5] in the electronic chart and 5.0 hazards (Q25-Q75: 3.0-6.75) in the paper chart (equivalence testing, p = 0.005). For the gastrointestinal bleeding case, the students identified a median of 5.0 hazards (Q25-Q75: 4.0-6.0) in the electronic chart and 5.0 hazards (Q25-Q75: 3.0-6.0) in the paper chart (equivalence testing, p < 0.001). We detected no improvement between the first case [median 5.0 (Q25-Q75: 3.0-6.0)] and second case [median, 5.0 (Q25-Q75: 3.0-6.0); p < 0.001, test for equivalence]. Electronic charts do not seem to facilitate advanced medical students' recognition of patient hazards during chart review and may impair expertise formation.

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Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record

Cited by 46 publications

References 29 publications

Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior

Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior

Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes

Electronic charts do not facilitate the recognition of patient hazards by advanced medical students: A randomized controlled study

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