Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions

Objective: To investigate whether using a computer-based patient record (CP R) affects the completeness of documentation and appropriateness of documen ted clinical decisions. Design: A blinded expert panel of four experienced internists evaluated 50 progress notes of patients who had chronic diseases and whose physicians us ed either a CPR or a traditional gaper record. Measurements: Completeness of problem and medication lists in progress note s, allergies noted in the entire record, consideration of relevant patient factors in the progress note's diagnostic and treatment plans, and appropri ateness of documented clinical decisions. Results: The expert reviewers rated the problem lists and medication lists in the CPR progress notes as more complete (1.79/2.00 vs. 0.93/2.00, P < 0. 001, and 1.75/2.00 vs. 0.91/2.00, P < 0.001, respectively) than those in th e paper record. The allergy lists in both records were similar. Providers u sing a CPR documented consideration of more relevant patient factors when m aking their decisions (1.53/2.00 vs. 1.07/2.00, P < 0.001), and documented more appropriate clinical decisions (3.63/5.00 vs. 2.50/5.00, P < 0.001), c ompared with providers who used traditional paper records. Conclusions: Physicians in our study who used a CPR produced more complete documentation and documented more appropriate clinical decisions, as judged by an expert review panel. Because the physicians who used the CPR in our study volunteered to do so, further study is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement i n documentation leads to better clinical outcomes.