1. Brandt, Kathleen RN, BSN

Article Content


Electronic medical records (EMRs) are intended to improve the accuracy and availability of data. This article reviewed current research articles as well as publications from respected journals on the quality of progress note documentation within the EMR.



A systematic literature review was performed using research articles and applicable publications with the keywords electronic medical records, accuracy, quality, and usability using MeSH terms in PubMed, Medline, and CINAHL. Studies were eliminated from review if the EMR was not the sole source of documentation. Seventeen studies were included in this review.



Quality was defined as data that are accurate, complete, relevant, and accessible. Three studies demonstrated incomplete and inaccurate documentation occurring in the electronic records of various disciplines and settings due to free text or prompted entries.1-3 Five studies at Veterans Affairs (VA) facilities examined the copying and pasting of notes within the EMR.4-8 It was found that 9% of progress notes had a copied event with 10% to 31% resulting in clinically misleading risky information (type 5 and 6 errors), with physical or mental examinations being the most frequent category. Authors copied either their own examination note or that of others in 25% of the charts. The most frequent authors of the copied notes were physicians (50% of all authors), who had the most copying errors (89% with a mean of two errors per note), followed by nurses (21%, with 1% copying errors) and medical students (11%, with 5% copying errors). Six studies and two papers suggested that this behavior is a result of a mismatch between the technology and the work flow of the healthcare providers.2,9-15 Finally, two studies examined the effect of changing user interface design to increase users' satisfaction and decrease input errors.16,17



A potential for misinformation and lack of easy access to and retrieval of information is a major cause for concern. More attention needs to be focused on user interface design and customization to the healthcare workers' work flow environment, which would improve user's satisfaction and trust of the information accuracy as well as decrease cognitive overload. Given the stellar history of the EMR within the VA, others may gain insight for this potential misinformation and redundancy of information as their documentation system matures. Furthermore, this review suggests the need for extended postimplementation evaluations.



Special thanks to Eun-Shim Nahm, PhD, MS, RN.




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