Some EHR documentation of patient visits to the emergency department may not always accurately represent physicians' actions and exams during patient encounters, according to a recent study published in JAMA.
University of California Los Angeles researchers led a study of nine licensed emergency physician residents and 12 observers to determine the accuracy of physician documentation in the EHR. One hundred-eighty patient encounters were observed.
The study was performed at two EDs in academic medical centers between 2016 and 2018. Patient encounters were observed to compare performance with clinical documentation. The resident physicians were shadowed by trained observers for 20 total encounters, which translated to 10 encounters per physician per site, to gather real-time observational data. Associated EHR data was reviewed and used to measure accuracy.
Results of the study showed 38.5 percent of documented reviews of systems were confirmed by audio recording data and 53.2 percent of physical examination systems were confirmed by concurrent observation.
Study authors concluded that because there were inconsistencies between ROS documentation and PE findings in the EHR, some of the EHR documentation therefore may not accurately represent physicians' actions. The researchers recommended expanding studies to determine whether this occurrence is widespread.