Electronic health records (EHR) may not accurately represent physical examinations conducted by emergency room physicians, according to study results published in JAMA Network Open. The study found that the percentage of unsubstantiated documentation, meaning inconsistencies between documentation and actual physical evaluation, was more common when information was less clinically relevant.
To study how well EHRs reflect actual physical examinations, investigators reviewed 180 cases (mean [SD] age, 48.7  years; 50.5% women) recorded by 9 resident physicians who were shadowed by 12 observers in 2 academic medical centers. Of these, 20 encounters (10 per physician per site) were recorded and the real-time observational data was compared with EHR data between 2016 and 2018.
This is the first study to compare the accuracy of electronic physician documentation using concurrent observation. The outcomes measured were the number of confirmed review of systems divided by the number of documented review of systems. The same measures were calculated for physical examination.
For review of systems, audio recording data confirmed 38.5% of documented reviews, and concurrent observation confirmed 53.2% of documented physical examination. “These results raise the possibility that some physician documentation may not accurately represent physician actions,” the investigators noted.
“Further studies should be undertaken in other clinical settings to determine whether this occurrence is widespread. However, because such studies are unlikely to be performed owing to institution-level barriers that exist nationwide, payers should consider removing financial incentives to generate lengthy documentation,” concluded the investigators.
Berdahl CT, Moran GJ, McBride O, Santini AM, Verzhbinksky IA. Concordance between electronic clinical documentation and physician’s observed behavior. JAMA Netw Open. 2019;2(9):e1911390.