Should documentation in Electronic Health Records (EHRs) prioritize quantity over quality?

From the Guidelines

No, documentation in Electronic Health Records (EHRs) should prioritize quality over quantity. High-quality documentation focuses on relevant clinical information, accurate diagnoses, clear treatment plans, and meaningful patient interactions rather than simply generating lengthy notes. According to the American College of Physicians, the primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up 1. Quality documentation improves patient care by ensuring that critical information is easily accessible and understandable to all healthcare providers involved in a patient's care. This includes clearly documenting medication details, allergies, past medical history, assessment findings, and follow-up plans. To implement quality-focused documentation immediately, clinicians should use structured templates appropriately, avoid excessive copy-pasting, include only pertinent information, and ensure documentation reflects actual patient encounters.

Some key points to consider when prioritizing quality over quantity in EHR documentation include:

• Using technology to facilitate efficient documentation without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians 1
• Focusing on concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up
• Avoiding defensive medicine practices that prioritize extensive documentation over relevant clinical information
• Ensuring documentation is accurate, complete, and easily accessible to all healthcare providers involved in a patient's care

By prioritizing quality over quantity in EHR documentation, clinicians can improve patient care, reduce the risk of medical errors, and decrease provider burnout while meeting regulatory requirements and supporting accurate billing and coding. As noted in the policy paper from the American College of Physicians, clinicians must help define and prioritize the many important roles that clinical documentation serves today 1.

From the Research

Documentation in EHRs: Quantity vs Quality

• The issue of prioritizing quantity over quality in Electronic Health Records (EHRs) documentation is a concern in the healthcare industry 2.
• A study published in 2015 proposed the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care 2.
• The study emphasized the need to optimize nurses' documentation efficiency while contributing to knowledge generation, and to attain a balance that ensures the capture of nursing's impact on safety, quality, and patient engagement.

Impact of Standardized Note Templates

• A 2021 study investigated the impact of standardized note templates on evaluation and management (E/M) charge capture and quality metrics, and found that accurate documentation of patient care and acuity is essential to determine appropriate reimbursement and quality metrics 3.
• The study found that a documentation and coding initiative using standardized note templates improved E/M charge capture, reimbursement, and quality metrics, including case mix index (CMI) and mortality index (MI) 3.

Patient Access to EHRs

• A 2021 systematic review found that patient access to their own EHRs via patient portals can have positive outcomes, including improved patient engagement, self-care, and health outcomes, as well as increased awareness and adherence to medication 4.
• However, the review also highlighted concerns around security, privacy, and confidentiality of health records, and the potential for anxiety amongst patients 4.

Effective Record-Keeping and Documentation

• A 2021 article emphasized the importance of effective record-keeping and documentation in nursing and healthcare, and outlined the principles for maintaining clear and accurate patient records 5.
• The article highlighted the need for healthcare professionals to prioritize record-keeping and documentation to support the provision of safe, high-quality patient care.

Conclusion Not Applicable

• As per the provided instructions, no conclusion will be drawn from the above points, and the response will only provide information based on the available evidence.
• It is worth noting that there is no direct evidence in the provided studies to suggest that documentation in EHRs should prioritize quantity over quality, but rather that a balance between the two is necessary to ensure accurate and effective documentation 2, 3, 4, 5.