"Data in EHRs Don't Match Physicians' Exam, Study Suggests" - Diana Swift
Electronic health records have the potential to improve the accuracy of medical documentation, but they may be having the opposite effect. A small study of patient visits to the emergency department reveals concerning inconsistencies between real-time observational data — what physicians were actually seen or heard to do during patient encounters — and what was documented in the medical records. “It is a well-thought-out observational study that overcomes the challenges of data collection, physician resistance to auditing, and the desire to preserve an image of physician infallibility," said Nathalie Jette, MD, MSc, professor of neurology, population health science and policy at the Icahn School of Medicine at Mount Sinai who was not involved in the study. “It is of vital importance for clinical health services and legal purposes that clinicians document medical record information consistent with the level of care given.”
— Nathalie Jette, MD, MSc, Professor, Neurology, Population Health Science and Policy, Icahn School of Medicine at Mount Sinai