Electronic health records improve clinical note quality

摘要: Background and objective The clinical note documents the clinician's information collection, problem assessment, management, its used for administrative purposes. Electronic health records (EHRs) are being implemented in practices throughout USA yet it is not known whether they improve quality of notes. goal this study was to determine if EHRs outpatient notes. Materials methods A five a half year longitudinal retrospective multicenter quantitative comparing handwritten electronic visit notes 100 patients with type 2 diabetes at three time points: 6 months prior introduction EHR (before-EHR), after (after-EHR), 5 years (5-year-EHR). QNOTE, validated instrument, assess Its scores can range from low 0 high 100. Sixteen primary care physicians active QNOTE 300 patient notes. Results before-EHR, after-EHR, 5-year-EHR grand mean (SD) were 52.0 (18.4), 61.2 (16.3), 80.4 (8.9), respectively, change before-EHR after-EHR 18% (p<0.0001) 55% (p<0.0001), respectively. All element significantly improved over 5-year interval. Conclusions overall all elements, including core non-core elements. To our knowledge, first demonstrate that improves