Differences Between What Is Said During the Consultation and What Is Recorded in the Electronic Health Record.

: 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.