Healthcare Innovation November 12, 2024
Discrepancies between what happened during the visit and what was actually recorded in the EHR have important care implications, Regenstrief Institute researchers say
A research study published in BMC Primary Care comparing the actual conversation between patient and clinician during a primary care appointment with the information subsequently entered by the clinician into the patient’s EHR has found significant disparities.
In the observational study conducted at five Veterans Affairs clinics in the Midwest, comparing what was said during a primary care appointment with the information entered into the patient’s EHR after the visit revealed that discussions of most issues initiated by patients were omitted from notes in the EHR. In addition, nearly half of the notes in the EHR referred...
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