Concordance Between Electronic Clinical Documentation and Physicians' Observed Behavior.

Area of Science:

• Medical Informatics
• Clinical Documentation Accuracy
• Emergency Medicine

Background:

• The transition to electronic health records (EHRs) has occurred within a regulatory framework designed for paper records.
• There is limited research on the accuracy of physician documentation in the EHR era.

Purpose of the Study:

• To determine the accuracy of emergency physician documentation by comparing it with observed patient encounters.
• To quantify the discrepancy between documented and confirmed review of systems (ROS) and physical examination (PE) findings.

Main Methods:

• A case series design was employed at two academic medical centers from 2016 to 2018.
• Trained observers shadowed nine resident physicians, recording 20 encounters per physician to capture real-time data.
• Observed data were compared with subsequent EHR documentation for ROS and PE.

Main Results:

• Physicians documented significantly more ROS (median 14 systems) than were confirmed by audio recordings (median 5 systems); only 38.5% of documented ROS were confirmed.
• For PE, physicians documented a median of 8 systems, while observers confirmed a median of 5.5 systems; 53.2% of documented PE findings were confirmed.
• High interrater reliability (over 90%) was achieved for rating ROS and PE.

Conclusions:

• Significant inconsistencies exist between emergency residents' EHR documentation of ROS and PE and their observed actions.
• This suggests that some EHR documentation may not accurately reflect actual physician performance.
• Given potential institutional barriers to further research, payers should consider eliminating financial incentives for extensive documentation.