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

摘要

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.