The Impact of Documentation Workflow on the Accuracy of the Coded Diagnoses in the Electronic Health Record

Abstract

Objective: To determine the impact of documentation workflow on the accuracy of coded diagnoses in electronic health records (EHRs). Design: Cross-sectional study. Participants: All patients who completed visits at the Casey Eye Institute Retina Division faculty clinic between April 7, 2022 and April 13, 2022. Main Outcome Measures: Agreement between coded diagnoses and clinical notes. Methods: We assessed the rate of agreement between the diagnoses in the clinical notes and the coded diagnosis in the EHR using manual review and examined the impact of the documentation workflow on the rate of agreement in an academic retina practice. Results: In 202 visits by 8 physicians, 78% (range, 22%–100%) had an agreement between the coded diagnoses and the clinical notes. When physicians integrated the diagnosis code entry and note composition, the rate of agreement was 87.9% (range, 62%–100%). For those who entered the diagnosis codes separately from writing notes, the agreement was 44.4% (22%–50%, P < 0.0001). Conclusion: The visit-specific agreement between the coded diagnosis and the progress note can vary widely by workflow. The workflow and EHR design may be an important part of understanding and improving the quality of EHR data. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Keywords

• Data quality
• Electronic health records
• Problem-oriented charting