Study: Patient Concerns Often Missing From Medical Records

A research study published in BMC Primary Care comparing the actual conversation between patient and clinician during a primary care appointment with the information subsequently entered by the clinician into the patient’s EHR has found significant disparities.

In the observational study conducted at five Veterans Affairs clinics in the Midwest, comparing what was said during a primary care appointment with the information entered into the patient’s EHR after the visit revealed that discussions of most issues initiated by patients were omitted from notes in the EHR. In addition, nearly half of the notes in the EHR referred to information or observations not found in the transcript of the actual medical encounter.

These discrepancies between what happened during the visit and what was actually recorded in the EHR have important care implications for both patients and clinicians with potential to affect care and outcomes, according to Michael Weiner, M.D., M.P.H., a U.S. Department of Veterans Affairs, Regenstrief Institute and the Indiana University School of Medicine research scientist, who led the report. A health services researcher and primary care physician, his research focuses on the use of technology to improve patient safety and medical outcomes.

“The core job of the clinician is to understand the patient's issues and then to organize them in a way that fosters an appropriate interpretation, diagnosis and, if needed, treatment plan,” said. Weiner, in a statement. “That process requires a transformation of what the patient is saying or doing and what the clinician finds upon examination into the clinician's interpretation of all of those findings. In turn, all of this information should be recorded in the EHR.”

The research team recorded patient appointments with their primary care physician or nurse practitioner for a routine visit, checkup or a specific problem. Psychosocial issues were commonly brought up during these appointments. The researchers found that when the clinician initiated discussion about these issues, 92 percent of notes in the EHR included them, but when the patient initiated discussion, only 45 percent did.

The researchers note that in addition to limited usability of EHR systems, reasons for omissions could include lack of recognition of the significance of a problem by clinicians, forgetfulness while writing notes, insufficient time to complete records accurately and thoroughly; belief that the issue had already been addressed; or prioritization of other concerns. Decreasing the time between the medical visit and writing notes in the EHR may be one means to improve both thoroughness and accuracy.

“The electronic health record is the de facto means of ensuring continuity of care for patients,” said study senior author Richard M. Frankel, Ph.D., of Regenstrief Institute and the IU School of Medicine, in a statement. “In an era in which face to face communication between physicians has given way to communicating via devices such as computers and smart phones, the accuracy and completeness of the record of care takes on additional importance.

“Our findings suggest that better alignment and education about what’s said and what’s documented in the EHR will ensure that both the quality of the care being delivered and attention to the human dimension of the patient’s biological, psychological, and social needs are present and accounted for.”

In 2023, Healthcare Innovation interviewed Weiner about research he and colleagues conducted on health system transitions to new electronic health record systems.