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Differences Between What Is Said During the Consultation and What Is Recorded in the Electronic Health Record
Virginie Lacroix-Hugues, Sarah Azincot-Belhassen, Pascal Staccini, David Darmon
674 - 678
10.3233/SHTI190308
Research Article
Studies in Health Technology and Informatics
Volume 264: MEDINFO 2019: Health and Wellbeing e-Networks for All
Abstract

Electronic Health Records (EHRs) can be used for research but this raises the problem of data quality.

Objective:

To evaluate the quality of the information recorded in an EHR by a general practitioner (GP) during a regular office consultation.

Method:

191 dialogs between the GP and patient were recorded and translated into the International Classification of Primary Care Second edition (ICPC-2) codes. Written information of the corresponding EHR was extracted and coded for comparison.

Results:

The primary reason for the consultation was recorded in the EHR in 41.2% of the cases and the diagnosis in 44.1% of the cases. Diagnoses noted in the EHR were less often communicated to the patients than the primary reasons (p<0.0001).

Conclusion:

There is a loss of information between the dialog during a consultation and what is reported in the EHR. Consequences in terms of continuity and safety of care can be expected.

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