Bottom Line: A study of nine emergency department residents reports inconsistencies between the electronic medical record and physicians' behaviors observed and recorded during patient encounters. Resident physicians were shadowed by trained observers for 20 encounters in this study conducted at emergency departments in two academic medical centers. The study quantified the review of systems (when patients are asked questions about different organs) and physical examinations documented by physicians and what observers confirmed. Physicians documented a median of 14 systems during the review of systems, while audio recordings confirmed a median of five. For physical examination, physicians documented a median of eight systems, while observers confirmed a median of 5.5. The study notes the electronic medical record could be prone to inaccuracy in those areas because of autopopulated information. Electronic medical records are used to generate bills. Limitations of the study include the small number of resident physicians and their behavior may not represent that of attending emergency physicians, also the observers may have missed things. Further research could help to determine if such inconsistencies are widespread.
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Authors: Carl T. Berdahl, M.D., M.S., of the National Clinician Scholars Program, University of California, Los Angeles, and coauthors, including David L. Schriger, M.D., M.P.H., of the University of California, Los Angeles, who is an associate editor of JAMA.
Editor's Note: The article includes conflict of interest and funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Media advisory: To contact corresponding author Carl T. Berdahl, M.D., M.S., email Enrique Rivero at email@example.com. The full study is linked to this news release.
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