Electronic Health Records in Ophthalmology: Source and Method of Documentation.

Abstract Purpose To analyze and quantify the source of electronic health record (EHR) text documentation in ophthalmology progress notes. Design EHR documentation review and analysis. Methods . Setting A single academic ophthalmology department. Study Population A cohort study conducted between November 1, 2016 and December 31 2018 using secondary EHR data, and a follow up manual review of a random sample. The cohort study included 123,274 progress notes documented by 42 attending providers; these notes were for patients with the 5 most common primary ICD 10 parent codes for each provider. For the manual review, 120 notes from 8 providers were randomly sampled. Main Outcome Measures Characters or number of words in each note categorized by attribution source, author type, and time of creation. Results Imported text entry made up the majority of text in new and return patients, 2978 characters (77%) and 3612 characters (91%) respectively. Support staff members authored substantial portions of notes, 3,024 characters (68%) of new patient notes, 3,953 characters (83%) of return patient notes. Finally, providers completed large amounts of documentation after clinical visits 135 words (35%) of new patient notes, 102 words (27%) of return patient notes. Conclusions EHR documentation consists largely of imported text, is often authored by support staff, and is often written after the end of a visit. These findings raise questions about documentation accuracy and utility, and may have implications for quality of care and patient-provider relationships.