Experience with the electronic patient record at a university ENT clinic from 2016 to 2021 using standardized documentation quality controls as part of quality management

Introduction In the course of digitalization and the increasing need for documentation, the Electronic Patient Record (EPR) has been established in everyday clinical practice at the ENT Clinic of the University of Frankfurt since 2015. A survey to identify sources of error and thus to improve the quality of documentation in the EPR is conducted regularly as part of quality management.

Method Since 2016, the documentation quality in the EPR has been examined annually on the basis of representative samples from all inpatient, operative cases. A standardized data entry form was developed for this purpose. In it, numerous items for checking content-related, technical and organizational aspects, divided into chapters (pre-inpatient phase, admission, surgery, postoperative phase, discharge) are checked and marked as missing (0), not assessable (1) and present (2) and were statistically evaluated.

Results Random and systematic errors were found in variable frequencies during the observation period from 2016 to 2021. These included the absence of certain record entries at certain points in the hospital stay (e.g., pre-op admission, post-op visit), incorrect selection of forms, incongruence of record entries to physician letters, or frequent "copy-paste" errors.

Conclusion In addition to the advantages of an EPR such as readability, evaluability, data security and variable simultaneous access, specific, repetitive errors could be identified. These could thus subsequently be minimized or eliminated by defining measures. It became apparent that there is a need for regular review as part of quality assurance. This serves both patient safety and the legal security of the practitioners.

Publication History

Article published online:
24 May 2022