Electronic Documentation of Patients’ Records: Completeness, Timeliness and Clinicians’ Views

Abstract

The implementation of the electronic health record opened opportunities to enhance the quality of care through collaborative decision-making and fast tracked documentation. However, in order to gain from the benefits of electronic health records (EHRs), data captured need to be complete and timely. This paper reports on the electronic documentation of patients’ records two years after the implementation of the EHR in an acute care hospital. The purpose was to assess the completeness and timeliness of electronic documentation and to elicit views of clinicians regarding the observed trends. Compliance was defined as availability of required documents and the presence of specific elements within the documents completed, within the stipulated time frame. The study used the hospital documentation policy to assess rate of compliance. A retrospective descriptive, explanatory design using electronic data extraction and structured checklists was utilised to collect quantitative data in five documents of In-Patient (IP) encounters. Semi-structured interviews were conducted with 6 clinicians, 4 physicians and 2 charge nurses. The rate of compliance showed a significant decline especially learning assessment, history and physical examination documentation. Clinicians cited both system and human issues as contributory factors.

Keywords: Electronic Health Record, Electronic Documentation, Completeness, Health Information System, Timeliness