Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical Decisions
- Affiliations of the authors: Northwestern University (PCT) and Northwestern Memorial Hospital (PCT, MPL, SMG), Chicago, Illinois
- Correspondence and reprints: Paul C. Tang, MD, 1270 Carmel Terrace, Los Altos, CA 94024. e-mail: 〈tang{at}smi.stanford.edu〉
- Received 23 July 1998
- Accepted 1 December 1998
Abstract
Objective To investigate whether using a computer-based patient record (CPR) affects the completeness of documentation and appropriateness of documented clinical decisions.
Design A blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians used either a CPR or a traditional paper record.
Measurements Completeness of problem and medication lists in progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress note's diagnostic and treatment plans, and appropriateness of documented clinical decisions.
Results The expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs. 0.93/2.00, P < 0.001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in the paper record. The allergy lists in both records were similar. Providers using a CPR documented consideration of more relevant patient factors when making their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), compared with providers who used traditional paper records.
Conclusions Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in documentation leads to better clinical outcomes.
Footnotes
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This research was conducted and the paper written when Dr. Tang was a full-time employee of Northwestern Memorial Hospital. He is currently at the Palo Alto Medical Foundation and is a part-time employee of Epic Systems, the vendor of the CPR software.
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This work was supported in part by contract N01-LM43509 from the National Library of Medicine.
