Correlation of patient entry rates and physician documentation errors in dictated and handwritten emergency treatment records.
This study was designed to examine the relationship between patient entry rates (a measure of physician work load) and documentation errors/omissions in both handwritten and dictated emergency treatment records. The study was carried out in two phases. Phase I examined handwritten records and Phase II examined dictated and transcribed records. A total of 838 charts for three common chief complaints (chest pain, abdominal pain, asthma/chronic obstructive pulmonary disease) were retrospectively reviewed and scored for the presence or absence of 11 predetermined criteria. Patient entry rates were determined by reviewing the emergency department patient registration logs. The data were analyzed using simple correlation and linear regression analysis. A positive correlation was found between patient entry rates and documentation errors in handwritten charts. No such correlation was found in the dictated charts. We conclude that work load may negatively affect documentation accuracy when charts are handwritten. However, the use of dictation services may minimize or eliminate this effect.
Dawdy
M R
MR
Department of Emergency Medicine, Naval Medical Center Portsmouth, VA 23708, USA.
Munter
D W
DW
Gilmore
R A
RA
D004282:Documentation / Q000379:methods* / Q000592:standards; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005431:Florida; D006236:Handwriting; D006772:Hospitals, Military; D006801:Humans; D016014:Linear Models; D008499:Medical Records / Q000592:standards*; D008505:Medical Staff, Hospital; D010343:Patient Admission / Q000592:standards*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D016526:Workload