Primary Care Encounter Notes Often Lack Thoroughness

MONDAY, Nov. 18, 2024 (HealthDay News) -- Physician electronic health record (EHR) notes of primary care patient encounters often lack thoroughness, according to a study recently published online in BMC Primary Care.

Michael Weiner, M.D., M.P.H., from the Indiana University Center for Health Services and Outcomes Research in Indianapolis, and colleagues assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality. The analysis included 49 encounters with 11 clinicians.

The researchers found that most issues that patients initiated in discussion were omitted from notes. Further, nearly half of notes referred to information or observations that could not be verified. Four notes lacked concluding assessments and plans, while nine notes lacked information about when patients should return. Physician Documentation Quality Instrument items that were assessed achieved quality scores exceeding 4 of 5 points, with the exception of thoroughness.

"Our findings suggest that better alignment and education about what’s said and what's documented in the EHR will ensure that both the quality of the care being delivered and attention to the human dimension of the patient's biological, psychological, and social needs are present and accounted for," senior author Richard M. Frankel, Ph.D., also from Indiana University, said in a statement.

One author disclosed ties to the health technology industry.

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