Accuracy, thoroughness, and quality of outpatient primary care documentation in the U.S. Department of Veterans Affairs
Michael Weiner,
Mindy E. Flanagan,
Katie Ernst
et al.
Abstract:Background
Electronic health records (EHRs) can accelerate documentation and may enhance details of notes, or complicate documentation and introduce errors. Comprehensive assessment of documentation quality requires comparing documentation to what transpires during the clinical encounter itself. We assessed outpatient primary care notes and corresponding recorded encounters to determine accuracy, thoroughness, and several additional key measures of documentation quality.
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