Physician progress notes tend to be more accurate in paper records than in newly implemented electronic health records, but there is more information omitted in paper notes, according to a new study in the Journal of the American Medical Informatics Association.
The researchers reviewed the initial progress notes of patients admitted to Beaumont Hospital in Royal Oak, Michigan, between August 2011 and July 2013. They retrospectively reviewed 500 notes, some before implementation of the EHR in 2012 and some after implementation, and studied five specific diagnoses with invariable physical findings: permanent atrial fibrillation, aortic stenosis, intubation, lower limb amputation and cerebrovascular accident with hemiparesis.
They found that overall accuracy of documentation was “poor”, with 54.4 percent accuracy of documentation of physical exam findings in paper records and 58.4 percent in EHRs. However, the rate of inaccurate documentation was “significantly” higher with EHRs (24.4 percent v. 4.4 percent). When it came to missing information, expected physical exam findings (such as the presence of a murmur) was more likely to be omitted in the paper notes (41.2 percent v. 17.6 percent).
Residents overall had fewer inaccuracies (5.3 percent v. 17.3 percent) and omissions (16.8 percent v. 33.9 percent) than attending physicians.
The study showed that the type of error was dependent on the system being used. The researchers surmised that omissions in paper were likely due to time constraints; inaccuracies were more common in EHRs due to the use of macros, templates and copied notes.
“During the initial phase of implementation of an EHR system, inaccuracies were more common in progress notes in EHRs compared to paper charts. ... As EHRs become more disseminated, research should focus on implementing training programs and incentives that support accurate documentation,” the authors said.
To learn more:
- here’s the abstract