title: Providers' Note-Writing Practices for Post-traumatic Stress Disorder at Five United States Veterans Affairs Facilities.
abstract: The capacity of electronic health records (EHRs) to capture desired information depends on the practices of health care providers. These practices have not been well studied in relation to post-traumatic stress disorder (PTSD). This qualitative study investigated how providers write EHR notes on PTSD through 38 interviews with providers working at five Veterans Affairs (VA) hospitals across the United States of America. Two overarching themes were prominent in the results. Providers used progress notes primarily to remember and access details for direct patient care, but only rarely for care coordination. Providers infrequently recorded information not judged to directly contribute to improved care, sometimes deliberately omitting information perceived to jeopardize patients' access to, or quality of, care. Omitted information frequently included sexual or non-military trauma. Understanding providers' thought processes can help clinicians be aware of the limitations of EHR notes as a tool for learning the histories of new patients. Similarly, researchers relying on EHR data for PTSD research should be aware of likely areas of missing data.
authors.affiliation: Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA. tuepker@ohsu.edu.|Division of General Internal Medicine, Oregon Health & Science University, Portland, OR, USA. tuepker@ohsu.edu.
authors.forename: Anaïs
authors.initials: A
authors.lastname: Tuepker
authors.affiliation: Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.|Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Susan L
authors.initials: SL
authors.lastname: Zickmund
authors.affiliation: UPMC Center for High-Value Health Care, Pittsburgh, PA, USA.
authors.forename: Cara E
authors.initials: CE
authors.lastname: Nicolajski
authors.affiliation: James A. Haley Veterans Hospital, Tampa, FL, USA.
authors.forename: Bridget
authors.initials: B
authors.lastname: Hahm
authors.affiliation: Consortium for Healthcare Informatics Research, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.
authors.forename: Jorie
authors.initials: J
authors.lastname: Butler
authors.affiliation: Consortium for Healthcare Informatics Research, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.
authors.forename: Charlene
authors.initials: C
authors.lastname: Weir
authors.affiliation: Department of Emergency Medicine, Yale University, New Haven, CT, USA.
authors.forename: Lori
authors.initials: L
authors.lastname: Post
authors.affiliation: Patient Centered Outcomes Research Institute (PCORI), Washington, DC, USA.
authors.forename: David H
authors.initials: DH
authors.lastname: Hickam
mesh_terms: D057286:Electronic Health Records; D006801:Humans; D010818:Practice Patterns, Physicians'; D013313:Stress Disorders, Post-Traumatic / Q000628:therapy*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000523:psychology*