Researchers reviewed 239 notes on patients with diabetes mellitus or coronary artery disease from 111 physicians, documenting the presence of various items in the notes with a nine-item checklist.
Several items were often missing from the notes, including reason for visit (10 percent), medication list (19. percent) and follow-up appointment information (18 percent).
Clinical outcomes for these patients were not correlated with the information physicians recorded or didn’t record in their notes.
The study concluded that while poorly written notes do not indicate bad care, well-written notes to not necessarily indicate good care. The authors noted individual physicians documented similar information in different locations within the electronic health record.
More Articles on Electronic Medical Records:
Study: Achieving Meaningful Use Reduces Hospital Costs, Helps Recoup IT Expenditures
How EHRs Can Measure Patient-Centered Care
US EHR Market To Hit $6B by 2015
At the Becker's 11th Annual IT + Revenue Cycle Conference: The Future of AI & Digital Health, taking place September 14–17 in Chicago, healthcare executives and digital leaders from across the country will come together to explore how AI, interoperability, cybersecurity, and revenue cycle innovation are transforming care delivery, strengthening financial performance, and driving the next era of digital health. Apply for complimentary registration now.