Doctors’ EHR note-taking method affects quality of care

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Physicians who have electronic health record systems but dictate patient notes give a lower quality of care than do doctors who use structured documentation, says a study published online May 19 in the Journal of the American Medical Informatics Association.


“Dictating may be easier for the doctor…[but he or she might] not be paying as close attention to information and alerts in the electronic health record that are important for patient health,” said lead study author Jeffrey A. Linder, MD, MPH, associate professor of medicine at Harvard Medical School in Boston.


Researchers evaluated 18,569 primary care visits by 7,000 patients with coronary artery disease or diabetes in eastern Massachusetts. The visits involved 234 doctors, and occurred between 2007 and 2008. Researchers also examined 188,554 patient visit notes written by the physicians for all of their patients.


They found that 62% of physicians mostly used free-text notes, 29% used structured documentation and 9% mainly dictated their notes. The structured format uses templates that divide the patient visit notes into separate sections, such as history of present illness.

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