Electronic medical documentation: Attitudes and trends among PAs in outpatient settings

To quantify PA attitudes about electronic-assisted documentation in the outpatient setting.

Survey data were collected from PAs to determine the documentation method used to record outpatient encounters. For clinicians using electronic-assisted documentation, information on the documentation style (including format of documentation, accuracy of generated encounters, and overall readability of encounters) was quantitatively measured.

129 PAs completed the survey and met the inclusion criteria of documenting outpatient encounters using an electronically assisted format. A statistically significant shift (P < .001) in documentation style from free-text formatted entries to structured data entry was seen as the volume of daily patient encounters increased. A statistically significant (P < .001) decrease in both accuracy and readability was noted with encounters using a structured data entry format.

In outpatient settings, a volume-dependent shift to structured data element documentation despite self-assessed deficiencies in both accuracy and readability was noted. This shift has the potential to negatively affect the integrity of medical documentation and raises patient safety concerns.