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J Am Med Inform Assoc 6:245-251 doi:10.1136/jamia.1999.0060245
  • Original Investigation

Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical Decisions

Table 2

Comparison of Completeness of Documentation and Appropriateness of Medical Decisions Made, Between Providers Who Used Computer-based Patient Records (CPRs) and Those Who Used Paper Records

Rating Dimension n CPR Users (Mean)/Highest Possible Score Paper-Record Users (Mean)/Highest Possible Score Significance
Major problems documented in problem list 169 1.79/2.00 0.93/2.00 <0.001
Medications documented in medication list 171 1.75/2.00 0.91/2.00 <0.001
Allergies documented in mini-record 169 1.97/2.00 1.85/2.00 0.07
Relevant clinical factors considered in assessment and plan 172 1.53/2.00 1.07/2.00 <0.001
Appropriateness of assessment and plan 172 3.63/5.00 2.50/5.00 <0.001

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