Assessing Provider-Generated Free-Text Quality in EHR-Integrated Handoff Notes

摘要：

　　Handoff notes are increasingly integrated within electronic health record(EHR)systems and often contain data automatically generated from the EHR and free-text narratives.We examined the quality of data entered by providers in the free-text portion of our institutional EHR handoff tool.Overall,65%of handoff notes contained at least one error(average 1.7 errors per note).Most errors were omissions in information around patient plan/management or assessment/diagnosis rather than entry of false data.Factors associated with increased error rate were increasing hospital day number; weekend note; medical(vs.surgical)service team; and authorship by a medical student,first or fourth year resident physician,or attending physician.Our findings suggest that errors are common in handoff notes,and while these errors are not completely false data,they may provide individuals caring for patients an inaccurate understanding of patient status.

关键词： Patient Handoff Patient Transfer Electronic Health Records

作者: Elliot G Arsoniadis Steven J Skube Treva M Bjerke Bryan Jarabek Genevieve B Melton

作者单位: Department of Surgery,University of Minnesota,Minneapolis,MN,USA;Institute for Health Informatics,Un Department of Surgery,University of Minnesota,Minneapolis,MN,USA Fairview Health Services,Minneapolis,MN,USA

会议类型: 国际会议

会议名称: 第十六届世界医药健康信息学大会((MEDINFO2017)、第二届世界医药健康信息学华语论坛(WCHIS 2017)、第15届全国医药信息学大会(CMIA 2017)

会议地点: 苏州

会议语种:英文

页码: 999-1003

在线出版日期: 2017-08-21（万方平台首次上网日期，不代表论文的发表时间）