8/30/2023 0 Comments M.e.a.t. clinical documentationOverall, 760 of 1429 verifiable documented PE systems (53.2%) were confirmed by concurrent observation. For PE, resident physicians documented a median (IQR) of 8 (7-9) verifiable systems, while observers confirmed a median (IQR) of 5.5 (3-6) systems. Overall, 755 of 1961 documented ROS systems (38.5%) were confirmed by audio recording data. For ROS, physicians documented a median (interquartile range ) of 14 (8-14) systems, while audio recordings confirmed a median (IQR) of 5 (3-6) systems. Results The final study cohort included 9 licensed emergency medicine residents who evaluated a total of 180 patients (mean age, 48.7 years 91 women). Main Outcomes and Measures Number of confirmed ROS systems (range, 0-14) divided by the number of documented ROS systems (range, 0-14), and number of confirmed PE systems (range, 0-14) divided by the number of documented PE systems (range, 0-14). Participants’ patient encounters were observed to compare real-time performance with clinical documentation.Įxposures Resident physicians were shadowed by trained observers for 20 encounters (10 encounters per physician per site) to obtain real-time observational data associated electronic health record data were subsequently reviewed. Objective To quantify the percentage of emergency physician documentation of the review of systems (ROS) and physical examination (PE) that observers can confirm.ĭesign, Setting, and Participants This case series took place at emergency departments in 2 academic medical centers between 20. Importance Following the adoption of electronic health records into a regulatory environment designed for paper records, there has been little investigation into the accuracy of physician documentation. Shared Decision Making and Communication.Scientific Discovery and the Future of Medicine.Health Care Economics, Insurance, Payment. ![]() Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography.Random jitter has been applied to scatterplot points to reduce superimposition of dots. The navy blue line represents the median number of systems on each histogram. The histograms show the distribution of the number of systems documented and discussed, again with orange and blue depicting overdocumentation and underdocumentation and gray representing neither. The dotted line represents ideal physician documentation behavior, ie, when documentation matches what transpired. ![]() A-C, Each dot represents 1 patient-physician encounter orange dots indicate that the number of systems documented exceeded the number observed, blue dots when the opposite occurred, and gray dots when the number of systems matched. C, Scatterplot depicting verifiable physical examination (PE) documentation and observation. B, The attestation of all ROS are negative is ignored, so systems directly documented are displayed. A, The assumption was that attestation of all review of systems (ROS) are negative denoted documentation of 14 systems.
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