It Rather Looks Like We Have A Big Problem With Clinical Data Capture – Especially When Comprehensive Notes Are Expected.

This appeared a few days ago:ED patient encounters not accurately documented in EHR By Greg SlabodkinSeptember 19, 2019, 12:08 a.m. EDT Documentation in electronic health records did not match observed and recorded physicians' behaviors during patient encounters, according to a study of emergency department residents.The study, published on Wednesday in the journal JAMA Network Open, involved emergency departments in two academic medical centers where residents ’ patient encounters were observed to compare real-time performance with EHR documentation.  “No other study has attempted to quantify the accuracy of electronic physician documentation using concurrent observation,” the authors contend.In the study, nine residents were shadowed by trained observers for 20 encounters—10 encounters per physician per site—to gather real-time observati onal data, with the associated EHR data subsequently reviewed. According to the authors, there were “inconsistencies” between the... This is the initial part of the post - read more by clicking on the title of the article. David.
Source: Australian Health Information Technology - Category: Information Technology Authors: Source Type: blogs