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Despite these limitations, the authors performed 1 of the few EHR information accuracy investigations using concurrent observation. It is a well—thought-out observational study that overcomes the challenges of data collection, physician resistance to auditing, and the desire to preserve an image of physician infallibility. It is of vital importance for clinical health services and legal purposes that clinicians document medical record information consistent with the level of care given.
While these findings raise the possibility that some documentation did not reflect physician actions, further studies are necessary to see how widespread this occurrence is within all specialties and whether this is also the case for attending physicians. There is also a need to investigate differing health systems.
An improved understanding of the root cause of discrepancies between patient report and physician documentation will be helpful in detecting ways to prevent them in the future. Health system accountability is becoming increasingly important for health policy makers and is ultimately necessary to ensure that patients receive the best possible care.
Further studies will be vital to better understand physician reporting behaviors and to identify optimal approaches to improve it. Published: September 18, No other disclosures reported. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
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