Journal of the American Medical Informatics Association : JAMIA
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J Am Med Inform Assoc · Jan 2017
Comparative StudyComparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.
There 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. ⋯ During 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.
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J Am Med Inform Assoc · Jan 2017
Randomized Controlled Trial Comparative StudyAn electronic documentation system improves the quality of admission notes: a randomized trial.
There are concerns that structured electronic documentation systems can limit expressivity and encourage long and unreadable notes. We assessed the impact of an electronic clinical documentation system on the quality of admission notes for patients admitted to a general medical unit. ⋯ An electronic admission documentation system improved both the quality of free-text content and the overall quality of admission notes. Authors wrote more in the free-text sections of electronic documents as compared to paper versions.
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J Am Med Inform Assoc · Jan 2017
Observational StudyComputer use, language, and literacy in safety net clinic communication.
Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients.We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL. ⋯ Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era.