TY - JOUR
T1 - Electronic Health Records in Ophthalmology
T2 - Source and Method of Documentation
AU - Henriksen, Bradley S.
AU - Goldstein, Isaac H.
AU - Rule, Adam
AU - Huang, Abigail E.
AU - Dusek, Haley
AU - Igelman, Austin
AU - Chiang, Michael F.
AU - Hribar, Michelle R.
N1 - Publisher Copyright:
© 2019 Elsevier Inc.
PY - 2020/3
Y1 - 2020/3
N2 - Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes. Design: EHR documentation review and analysis. Methods: SETTING: a single academic ophthalmology department. STUDY POPULATION: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation. Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes. Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.
AB - Purpose: This study analyzed and quantified the sources of electronic health record (EHR) text documentation in ophthalmology progress notes. Design: EHR documentation review and analysis. Methods: SETTING: a single academic ophthalmology department. STUDY POPULATION: a cohort study conducted between November 1, 2016, and December 31, 2018, using secondary EHR data and a follow-up manual review of a random samples. The cohort study included 123,274 progress notes documented by 42 attending providers. These notes were for patients with the 5 most common primary International Statistical Classification of Diseases and Related Health Problems, version 10, parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main outcome measurements were characters or number of words in each note categorized by attribution source, author type, and time of creation. Results: Imported text entries made up the majority of text in new and return patients, 2,978 characters (77%) and 3,612 characters (91%). Support staff members authored substantial portions of notes; 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits: 135 words (35%) of new patient notes, 102 words (27%) of return patient notes. Conclusions: EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility and may have implications for quality of care and patient-provider relationships.
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U2 - 10.1016/j.ajo.2019.11.030
DO - 10.1016/j.ajo.2019.11.030
M3 - Article
C2 - 31811860
AN - SCOPUS:85077919457
SN - 0002-9394
VL - 211
SP - 191
EP - 199
JO - American journal of ophthalmology
JF - American journal of ophthalmology
ER -