ArticleJournal of the American Medical Informatics Association : JAMIA2017
Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.
Article in Journal of the American Medical Informatics Association : JAMIA, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 33 papers, 2 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
33 citing papers in PubMed, 2 syntheses or guidelines pooled it, 53 citations in OpenAlex.
- Electronic health record data quality assessment and tools: a systematic review.Journal of the American Medical Informatics Association : JAMIA · 2023Pooled it
- The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals-A Systematic Review.Journal of medical systems · 2022Pooled it
- Electronic charts do not facilitate the recognition of patient hazards by advanced medical students: A randomized controlled study.PloS one · 2020Trial
- Development of an electronic system for self/proxy symptom tracking alongside children with cancer and their caregivers: a co-design exemplar.Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer · 2025Article
- Charting Diagnostic Safety: Exploring Patient-Provider Discordance in Medical Record Documentation.Journal of general internal medicine · 2025Article
- Protocol for improving equity in quantitative big data cleaning: lessons from longitudinal analysis of electronic health records from underrepresented and marginalized communities.International journal of epidemiology · 2025Article
- Assessing Physician and Patient Agreement on Whether Patient Outcomes Captured in Clinical Progress Notes Reflect Treatment Success: Cross-Sectional Study.Journal of participatory medicine · 2025Article
- Development of a text mining algorithm for identifying adverse drug reactions in electronic health records.JAMIA open · 2024Article
- PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.The Lancet. Child & adolescent health · 2024Observational
- Addressing label noise for electronic health records: insights from computer vision for tabular data.BMC medical informatics and decision making · 2024Article
- Frameworks, Dimensions, Definitions of Aspects, and Assessment Methods for the Appraisal of Quality of Health Data for Secondary Use: Comprehensive Overview of Reviews.JMIR medical informatics · 2024Review
- The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis.JMIR medical informatics · 2024Article
- I'm not burned out. This is how I write notes.JAMIA open · 2023Article
- Benefits, barriers, and facilitators of using speech recognition technology in nursing documentation and reporting: A cross-sectional study.Health science reports · 2023Article
- Automating Electronic Health Record Data Quality Assessment.Journal of medical systems · 2023Review
- Writing Practices Associated With Electronic Progress Notes and the Preferences of Those Who Read Them: Descriptive Study.Journal of medical Internet research · 2021Article
- Machine Learning for Detection of Correct Peripherally Inserted Central Catheter Tip Position from Radiology Reports in Infants.Applied clinical informatics · 2021Article
- Identification of obstetric anal sphincter injuries (OASIs) and other lacerations: a national survey of nurse-midwives.International urogynecology journal · 2021Article
- Assessing the quality of clinical and administrative data extracted from hospitals: the General Medicine Inpatient Initiative (GEMINI) experience.Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Challenges in the implementation of electronic systems for patient report of symptoms in oncology: a scoping review.Journal of hospital management and health policy · 2021Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
8 authors at 3 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
introductionThere have been several concerns about the quality of documentation in electronic health records (EHRs) when compared to paper charts. This study compares the accuracy of physical examination findings documentation between the two in initial progress notes. METHODOLOGY: Initial progress notes from patients with 5 specific diagnoses with invariable physical findings admitted to Beaumont Hospital, Royal Oak, between August 2011 and July 2013 were randomly selected for this study. A total of 500 progress notes were retrospectively reviewed. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm. The primary endpoints were accuracy, inaccuracy, and omission of information. Secondary endpoints were time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training.
resultsThe rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts (24.4% vs 4.4%). However, expected physical examination findings were more likely to be omitted in the paper notes compared to EHRs (41.2% vs 17.6%). Resident physicians had a smaller number of inaccuracies (5.3% vs 17.3%) and omissions (16.8% vs 33.9%) compared to attending physicians.
conclusionsDuring the initial phase of implementation of an EHR, inaccuracies were more common in progress notes in the EHR compared to the paper charts. Residents had a lower rate of inaccuracies and omissions compared to attending physicians. Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.