Emergency departments (EDs) using electronic health records (EHRs) may find inconsistencies between what is documented in the EHR and what has been observed in real-time by the physician, verifying less than 40% of review of systems (ROS) and just over 50% of physical examination (PE) systems, according to a recent study published in JAMA.
Nine licensed emergency physician residents and 12 observers were led by University of California Los Angeles researchers at two EDs in academic medical centers between 2016 and 2018 to determine the accuracy of physician EHR documentation, observing 180 patient encounters.
Carl T. Berdahl, MD, MS, from the National Clinician Scholars Program at the University of California, Los Angeles, and co-author of the study, notes that the errors observed tend to be unrelated to the complaints that originally brought the patient in. Researchers found EHR documentation of uncorroborated abdominal or genitourinary examination in just 3 of 55 instances (5.4%) among patients presenting with gastrointestinal or genitourinary problems. The same group documented an unsubstantiated ear, nose, and/or throat examination in 27 of 33 instances (81.8%).
"First, these are outstanding doctors doing a very good job, and their first order of business is to address patients' concerns. In order to get to the next bedside, they may do things to save time and take shortcuts that could add data to the charts that observers don't see during the encounters," Dr. Berdahl told Medscape Medical News.
Another possible driver of discrepancy is billing. The study did not look into circumstances regarding billing, but Dr. Berdahl mentioned that "[t]here are pressures to write more on the charts because you can charge more."
Due to inconsistencies between ROS documentation and PE findings, the authors of the study concluded that some of the EHR documentation may not accurately represent physicians’ actions and recommend expanding studies into determining whether this occurrence is widespread.