Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs.
BMC Prim Care
; 25(1): 262, 2024 Jul 18.
Article
en En
| MEDLINE
| ID: mdl-39026167
ABSTRACT
BACKGROUND:
Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality.METHODS:
Patients and primary care clinicians across five midwestern primary care clinics of the US Department of Veterans Affairs were recruited into a prospective observational study. Clinical encounters were video-recorded and transcribed verbatim. Using the Physician Documentation Quality Instrument (PDQI-9) added to other measures, reviewers scored quality of the documentation by comparing transcripts to corresponding encounter notes. PDQI-9 items were scored from 1 to 5, with higher scores indicating higher quality.RESULTS:
Encounters (N = 49) among 11 clinicians were analyzed. Most issues that patients initiated in discussion were omitted from notes, and nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans; nine lacked information about when patients should return. Except for thoroughness, PDQI-9 items that were assessed achieved quality scores exceeding 4 of 5 points.CONCLUSIONS:
Among outpatient primary care electronic records examined, most issues that patients initiated in discussion were absent from notes, and nearly half of notes referred to information or observations absent from transcripts. EHRs may contribute to certain kinds of errors. Approaches to improving documentation should consider the roles of the EHR, patient, and clinician together.Palabras clave
Texto completo:
1
Banco de datos:
MEDLINE
Asunto principal:
Atención Primaria de Salud
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United States Department of Veterans Affairs
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Documentación
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Registros Electrónicos de Salud
Límite:
Aged
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Female
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Humans
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Male
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Middle aged
País/Región como asunto:
America do norte
Idioma:
En
Revista:
BMC Prim Care
Año:
2024
Tipo del documento:
Article
País de afiliación:
Estados Unidos