دورية أكاديمية

Impact of Patient Load on the Quality of Electronic Medical Record Documentation

التفاصيل البيبلوغرافية
العنوان: Impact of Patient Load on the Quality of Electronic Medical Record Documentation
المؤلفون: Jacob, Aasems, Raj, Rishi, Alagusundaramoorthy, Sayee, Wei, Jing, Wu, Jianrong, Eng, Margaret
المصدر: Internal Medicine Faculty Publications
بيانات النشر: UKnowledge
سنة النشر: 2021
المجموعة: University of Kentucky: UKnowledge
مصطلحات موضوعية: EMR, documentation, patient load, residents, documentation quality, electronic medical records, call status, responsible electronic documentation checklist, Internal Medicine, Medical Education, Statistics and Probability
الوصف: Objective: American College of Graduate Medical Education (ACGME) recommends ongoing care of 10 patients per resident however its implication is unclear. We hypothesized EMR quality to vary based on patient load and call status. Methods: We conducted a double-blind, single-center, retrospective observational study between 2017 and 2019 to investigate the quality and accuracy of resident documentation using the Responsible Electronic Documentation (RED) Checklist, a validated scoring system. Results: A total of 234 independent charts were analyzed and 80 met scoring criteria. Average patients per residents was 4, 9.1, 7.2, and 5.5 on “call” day (D0), “post-call” day (D1), “mid-call” day (D2), and “pre-call” day (D3), respectively. Mean RED checklist scores were 68.1%, 57%, 68.6%, and 72.1% on the above call status. The difference in score between D3 and D1 was statistically significant (P = .00042). There was a negative correlation between score and number of patients per resident (r = −0.286, P = .010). Conclusion: EMR documentation quality is directly impacted by patient load and resident call status with the lowest documentation quality on post-call day, correlating with patient load.
نوع الوثيقة: text
وصف الملف: application/pdf
اللغة: unknown
العلاقة: https://uknowledge.uky.edu/internalmedicine_facpub/228Test; https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1228&context=internalmedicine_facpubTest
الإتاحة: https://uknowledge.uky.edu/internalmedicine_facpub/228Test
https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1228&context=internalmedicine_facpubTest
رقم الانضمام: edsbas.79B9C76A
قاعدة البيانات: BASE