Bradley S Henriksen1, Isaac H Goldstein1, Adam Rule2, Abigail E Huang1, Haley Dusek1, Austin Igelman1, Michael F Chiang2, Michelle R Hribar3. 1. Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA. 2. Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA. 3. Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA. Electronic address: hribarm@ohsu.edu.
Abstract
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.
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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