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Medicine and Health Sciences Commons

Open Access. Powered by Scholars. Published by Universities.®

Medical Education

University of Kentucky

2021

Documentation quality

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Full-Text Articles in Medicine and Health Sciences

Impact Of Patient Load On The Quality Of Electronic Medical Record Documentation, Aasems Jacob, Rishi Raj, Sayee Alagusundaramoorthy, Jing Wei, Jianrong Wu, Margaret Eng Jan 2021

Impact Of Patient Load On The Quality Of Electronic Medical Record Documentation, Aasems Jacob, Rishi Raj, Sayee Alagusundaramoorthy, Jing Wei, Jianrong Wu, Margaret Eng

Internal Medicine Faculty Publications

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 …