Abstract
Background In a time-constrained clinical environment, physicians cannot feasibly document all
aspects of an office visit in the electronic health record (EHR). This is especially
true for patients with multiple chronic conditions requiring complex clinical reasoning.
It is unclear how physicians prioritize the documentation of health information in
the EHR.
Objective The goal of this study is to examine documentation tradeoffs made by physicians when
caring for complex patients by comparing the content of office visit conversations
with resulting EHR documentation.
Methods We used grounded theory method of qualitative analysis to assess emergent themes
in the transcripts of 10 office visits, and then compared the themes to documentation
in the EHR. Differences between discussion and subsequent documentation of social
and emotional health topics and each of the other key categories were compared using
the Wilcoxon signed-rank test.
Results The categories that emerged included “chronic conditions,” “acute/new problems,”
“disease prevention,” and “social and emotional health.” We found that when social
and emotional topics were discussed in the office visit, it was documented in the
medical record only 30.6% of the time. Chronic conditions, acute/new problems, and
disease prevention were documented in the EHR between 87.5 and 91.7% of the time after
discussion. The differences between discussion and documentation of social and emotional
topics were significantly greater than the differences for chronic conditions, acute/new
problems, and disease prevention (all p < 0.05).
Conclusion Social and emotional factors, while extremely relevant to health management, are
less likely than medical concerns to be documented after discussion in an office visit.
This lack of documentation may hinder interdisciplinary communication between teams
informing individualized therapeutic decisions during acute care handoffs, such as
outpatient to inpatient care.
Keywords
electronic health record - documentation - social determinants of health - multiple
chronic conditions
