ArticleApplied clinical informatics2019
Electronic Health Record Documentation Patterns of Recorded Primary Care Visits Focused on Complex Communication: A Qualitative Study.
Article in Applied clinical informatics, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers.
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Who cites it
12 citing papers in PubMed.
- How a Digital Case Management Platform Affects Community-Based Palliative Care of Sub-Saharan African Cancer Patients: Clinician-Users' Perspectives.Applied clinical informatics · 2022Trial
- Determining patient eligibility for a physical activity referral scheme through EHR data extraction.BMC medical informatics and decision making · 2025Article
- A Directed Content Analysis of Discussions Between Mothers and Pediatricians Around Feeding and Growth Topics During Infant Well-Child Visits.Clinical pediatrics · 2025Article
- Patient-Reported Symptoms Compared With Nephrologist Documentation During Outpatient Visits: A Retrospective Patient-Reported Outcome Measures Study.Kidney medicine · 2025Article
- Clinician and Patient Perspectives on the Exchange of Sensitive Social Determinants of Health Information.JAMA network open · 2024Article
- Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy.Journal of the American Geriatrics Society · 2024Article
- Assessing the Assessment-Developing and Deploying a Novel Tool for Evaluating Clinical Notes' Diagnostic Assessment Quality.Journal of general internal medicine · 2023Article
- How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care.BMJ open · 2023Article
- Do nurses document all discussions of patient problems and nursing interventions in the electronic health record? A pilot study in home healthcare.JAMIA open · 2022Article
- Prevalence and Factors Associated with Patient-Requested Corrections to the Medical Record through Use of a Patient Portal: Findings from a National Survey.Applied clinical informatics · 2022Article
- Needs and Perspectives of Cancer Center Stakeholders for Access to Patient Values in the Electronic Health Record.JCO oncology practice · 2021Article
- A Novel Patient Values Tab for the Electronic Health Record: A User-Centered Design Approach.Journal of medical Internet research · 2021Article
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Authors and funding
7 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundIn a time-constrained clinical environment, physicians cannot feasibly document all aspects of an office visit in the electronic health record (EHR). This is especially true for patients with multiple chronic conditions requiring complex clinical reasoning. It is unclear how physicians prioritize the documentation of health information in the EHR.
objectiveThe goal of this study is to examine documentation tradeoffs made by physicians when caring for complex patients by comparing the content of office visit conversations with resulting EHR documentation.
methodsWe used grounded theory method of qualitative analysis to assess emergent themes in the transcripts of 10 office visits, and then compared the themes to documentation in the EHR. Differences between discussion and subsequent documentation of social and emotional health topics and each of the other key categories were compared using the Wilcoxon signed-rank test.
resultsThe categories that emerged included "chronic conditions," "acute/new problems," "disease prevention," and "social and emotional health." We found that when social and emotional topics were discussed in the office visit, it was documented in the medical record only 30.6% of the time. Chronic conditions, acute/new problems, and disease prevention were documented in the EHR between 87.5 and 91.7% of the time after discussion. The differences between discussion and documentation of social and emotional topics were significantly greater than the differences for chronic conditions, acute/new problems, and disease prevention (all
conclusionSocial and emotional factors, while extremely relevant to health management, are less likely than medical concerns to be documented after discussion in an office visit. This lack of documentation may hinder interdisciplinary communication between teams informing individualized therapeutic decisions during acute care handoffs, such as outpatient to inpatient care.
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