A new study in JAMA found inconsistencies between the way emergency department residents documented patient encounters in an EHR and what trained observers witnessed, writes Healthcare Dive. In the study, 12 observers (including two physicians and 10 undergraduate students with an interest in medicine) shadowed nine physicians during 180 patient encounters in the emergency departments of two teaching hospitals, which weren’t identified. They focused their observations on two parts of each encounter: the review of systems, where physicians ask patients about their symptoms, and the physical exam. The encounters were recorded. Residents documented a median of 14 systems (or organs in the body) as being discussed with patients during the review of systems portion of the encounter, while observers recorded a median of five systems, the study found. During the physical exams, physicians documented a median of eight systems examined per encounter, while observers noted a median of 5.5.
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