EHRs can Improve Clinical Note Quality
Written by Editor   
Thursday, November 06, 2014 10:07 AM

Physicians' clinical notes improved in quality after EHR implementation, according to an article published in the Journal of the American Medical Informatics Association (JAMIA).  The researchers noted there currently is no standard to assess note quality so there is no feasible way to provide physicians with feedback to improve their clinical notes, But researchers from the Uniformed Services University of the Health Sciences in Maryland conducted a five-year multicenter study of the quality of handwritten and electronic outpatient clinical visit notes.  The notes were evaluated six months before EHR implementation, six months after implementation and five years after implementation.

Note quality "significantly improved" over five years but some improved in just the first six months after EHR implementation. The largest improvements were in problem lists, past medical history, social and family history and review of systems.