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PSNet: Patient Safety Network
Journal Article

Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.

Yadav S, Kazanji N, C NK, et al. Journal of the American Medical Informatics Association : JAMIA. 2017;24:140-144.

Compared to paper charts, electronic health records offer safety benefits for physician documentation including better availability and legibility. However, electronic documentation introduces new concerns, such as copy-and-paste practices (which can perpetuate errors) and lack of diagnostic reasoning in electronic notes. This study compared physical exam documentation in initial physician progress notes before and after implementation of an electronic health record. Investigators found more inaccuracies in electronic notes, but more errors of omission in paper charts. Trainee physicians' documentation had fewer errors in both paper and electronic formats. The authors recommend that hospitals discourage copied notes and encourage accurate documentation at the time of the patient encounter. The importance of the physical examination itself was discussed in a PSNet interview with Dr. Abraham Verghese.