Study: Proper EHR documentation can reduce diagnosis errors

Tools

Much of the literature on medical errors has focused on medication administration and adherence to clinical guidelines for various procedures. Though misdiagnosis remains a huge problem in medicine, it has received less attention.

A new paper in the New England Journal of Medicine by Dr. Gorden Schiff and Dr. David W. Bates of Brigham and Women's Hospital and the Harvard School of Public Health in Boston examines how clinical documentation in electronic health records can help reduce diagnostic errors.

"Although clinical documentation plays a central role in EHRs and occupies a substantial proportion of physicians' time, documentation practices have largely been dictated by billing and legal requirements," they write. "Clinicians need to take back ownership of the medical record as a tool for improving patient care; such a move could have many benefits, including reducing the frequency of diagnostic errors."

According to Schiff and Bates, EHRs can help physicians make more accurate diagnoses by: 

* organizing and filtering patients' medical history and test results;
* facilitating collaboration between clinicians and patients;
* allowing for constant refinement and updating of patient data;
* improving communication in ordering tests and tracking results;
* providing clinical decision support to make sure physicians ask the right questions and consider the right diagnoses; and
* improving follow-up and patient education.

For more:
- read the full NEJM article
- take a look at this Medscape story (reg. req.)

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