This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tang, P. C. Articles by Gorden, S. M. Search for Related Content PubMed PubMed Citation Articles by Tang, P. C. Articles by Gorden, S. M.

Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical Decisions

Northwestern University (PCT) and Northwestern Memorial Hospital (PCT, MPL, SMG), Chicago, Illinois.

Correspondence and reprints: Paul C. Tang, MD, 1270 Carmel Terrace, Los Altos, CA 94024. e-mail: <tang{at}smi.stanford.edu>.

Objective: To investigate whether using a computer-based patient record (CPR) affects the completeness of documentation and appropriateness of documented clinical decisions.

Design: A blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians used either a CPR or a traditional paper record.

Measurements: Completeness of problem and medication lists in progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress note's diagnostic and treatment plans, and appropriateness of documented clinical decisions.

Results: The expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs. 0.93/2.00, P < 0.001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in the paper record. The allergy lists in both records were similar. Providers using a CPR documented consideration of more relevant patient factors when making their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), compared with providers who used traditional paper records.

Conclusions: Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in documentation leads to better clinical outcomes.

This article has been cited by other articles:

				P. D. Stetson, F. P. Morrison, S. Bakken, S. B. Johnson, and eNote Research Team Preliminary Development of the Physician Documentation Quality Instrument J. Am. Med. Inform. Assoc., July 1, 2008; 15(4): 534 - 541. [Abstract] [Full Text] [PDF]

				T. Schleyer, H. Spallek, and P. Hernandez A Qualitative Investigation of the Content of Dental Paper-based and Computer-based Patient Record Formats J. Am. Med. Inform. Assoc., July 1, 2007; 14(4): 515 - 526. [Abstract] [Full Text] [PDF]

				S. H. Brown, L. F. Fischetti, G. Graham, J. Bates, A. E. Lancaster, D. McDaniel, J. Gillon, M. Darbe, and R. M. Kolodner Use of Electronic Health Records in Disaster Response: The Experience of Department of Veterans Affairs After Hurricane Katrina Am J Public Health, April 1, 2007; 97(Supplement_1): S136 - S141. [Abstract] [Full Text] [PDF]

				P. C. Tang, M. Ralston, M. F. Arrigotti, L. Qureshi, and J. Graham Comparison of Methodologies for Calculating Quality Measures Based on Administrative Data versus Clinical Data from an Electronic Health Record System: Implications for Performance Measures J. Am. Med. Inform. Assoc., January 1, 2007; 14(1): 10 - 15. [Abstract] [Full Text] [PDF]

				J. S. Luo, D. M. Hilty, L. L. Worley, and J. Yager Considerations in Change Management Related to Technology Acad Psychiatry, December 1, 2006; 30(6): 465 - 469. [Abstract] [Full Text] [PDF]

				C. J. Wang, R. S. Marken, R. C. Meili, J. B. Straus, A. B. Landman, and D. S. Bell Functional Characteristics of Commercial Ambulatory Electronic Prescribing Systems: A Field Study J. Am. Med. Inform. Assoc., May 1, 2005; 12(3): 346 - 356. [Abstract] [Full Text] [PDF]

				P. J. Embi, T. R. Yackel, J. R. Logan, J. L. Bowen, T. G. Cooney, and P. N. Gorman Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians J. Am. Med. Inform. Assoc., July 1, 2004; 11(4): 300 - 309. [Abstract] [Full Text] [PDF]

				S. T. Rosenbloom, J. Grande, A. Geissbuhler, and R. A. Miller Experience in Implementing Inpatient Clinical Note Capture via a Provider Order Entry System J. Am. Med. Inform. Assoc., July 1, 2004; 11(4): 310 - 315. [Abstract] [Full Text] [PDF]

				J. Hippisley-Cox, M. Pringle, R. Cater, A. Wynn, V. Hammersley, C. Coupland, R. Hapgood, P. Horsfield, S. Teasdale, and C. Johnson The electronic patient record in primary care--regression or progression? A cross sectional study BMJ, June 25, 2003; 326(7404): 1439 - 1443. [Abstract] [Full Text] [PDF]

				G. Makoul, R. H. Curry, and P. C. Tang The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters J. Am. Med. Inform. Assoc., November 1, 2001; 8(6): 610 - 615. [Abstract] [Full Text] [PDF]