Assessing Resident Perceptions of Electronic Medical Record Utilization What Affects the Quality of Clinical Notes?

Objective review of orthopedic resident medical records revealed significant variation in quality of clinical notes suggesting that the implementation of the electronic medical record (EMR) had altered resident perceptions of the purpose of clinical documentation.

The purpose of this study was to assess resident perceptions of the purpose and use of the EMR.

An 84-item survey was developed based on previously validated surveys. All 62 orthopedic residents within one academic institution completed the survey. Questions were divided into six domains and domain scores were calculated by summing responses within each domain; a more negative response on the Likert scale received a higher score. Scores were compared across postgraduate year (PGY).

Survey results revealed that most residents agreed that they generally write good patient care notes, their notes contribute to the care of the patient, and as physicians they feel responsible for the accuracy of the information they enter into the EMR. However, residents were divided as to whether they have enough time to write a good patient care note. Domain scores did not significantly differ by PGY indicating that perceptions toward the EMR do not change even as residents increase their knowledge of orthopedics and become more skilled physicians.

Although residents recognize that the information they enter in the EMR is valuable for patient care and safety, some feel unable to consistently utilize the EMR to its full potential due to time constraints.