title: Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.
abstract: 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.
  
  
  
  Initial progress notes from patients with 5 specific diagnoses with invariable physical findings admitted to Beaumont Hospital, Royal Oak, between August 2011 and July 2013 were randomly selected for this study. A total of 500 progress notes were retrospectively reviewed. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm. The primary endpoints were accuracy, inaccuracy, and omission of information. Secondary endpoints were time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training.
  
  
  
  The rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts (24.4% vs 4.4%). However, expected physical examination findings were more likely to be omitted in the paper notes compared to EHRs (41.2% vs 17.6%). Resident physicians had a smaller number of inaccuracies (5.3% vs 17.3%) and omissions (16.8% vs 33.9%) compared to attending physicians.
  
  
  
  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.
authors.affiliation: Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan Siddhartha.yadav@beaumont.edu.|Nancy and James Grosfeld Cancer Genetics Center, Beaumont Health, Royal Oak, Michigan.
authors.forename: Siddhartha
authors.initials: S
authors.lastname: Yadav
authors.affiliation: Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan.
authors.forename: Noora
authors.initials: N
authors.lastname: Kazanji
authors.affiliation: Department of Hospital Medicine, Springfield Clinic, Springfield, Illinois.
authors.forename: Narayan
authors.initials: N
authors.lastname: K C
authors.affiliation: Division of Cardiology, Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan.
authors.forename: Sudarshan
authors.initials: S
authors.lastname: Paudel
authors.affiliation: Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan.
authors.forename: John
authors.initials: J
authors.lastname: Falatko
authors.affiliation: Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan.
authors.forename: Sandor
authors.initials: S
authors.lastname: Shoichet
authors.affiliation: Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan.
authors.forename: Michael
authors.initials: M
authors.lastname: Maddens
authors.affiliation: Department of Internal Medicine, Beaumont Health, Royal Oak, Michigan.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Barnes
mesh_terms: D000368:Aged; D000068598:Data Accuracy; D004282:Documentation / Q000379:methods / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D010209:Paper; D010808:Physical Examination; D012189:Retrospective Studies
keywords: EHR; EMR; accuracy; electronic health record; inaccuracy; paper chart; physical examination