The researchers — led by Nita G. Valikodath, a medical student at University of Michigan Medical School in Ann Arbor — identified 162 patients at ophthalmology and cornea clinics, who were asked to complete a self-reported eye symptom questionnaire.
The researchers defined documentation as inconsistent if a patient reported a moderate to severe symptom on the questionnaire that was not reflected in the EMR. Documentation was inconsistent for glare (48.1 percent), blurry vision (33.8 percent), pain or discomfort (26.5 percent) and redness (24.7 percent).
The researchers concluded: “These results suggest that documentation of symptoms based on EMR data may not provide a comprehensive resource for clinical practice or ‘big data’ research.”
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