A Comparison of Musculoskeletal Exam Documentation in Two Electronic Health Record Systems

Abstract

Introduction Electronic Health Record (EHR) systems have changed the way physicians record their exams.  Several studies have reviewed the quality of these transcribed exams; some of which have found with regard to arthritic and musculoskeletal conditions significant omissions in the recorded exam.   Methods Inpatients charts for patients receiving rheumatology consultations at 2 different Indiana hospital systems, both employing unique EHRs, were reviewed.   Notes were evaluated for the presence of four major musculoskeletal criteria: axial skeleton, upper extremity, lower extremity, and muscular exams.  Exam completeness was assessed by evaluating more specific examination documentation within these major groups.  Simple two sided Pearson Chi Square tests were used to assess all other individual patient and management dependent variables for the significance of the effect on exam documentation.    Results 44 study patient cases were reviewed.  Of the management dependent variables, the most significant one in affecting the likelihood of a thorough MSK examination being recorded was the location of the patient (p=0.017).  Patients admitted through the Emergency room compared to direct admits or ICU transfers were more likely to have an MSK exam recorded.  The more detailed exams were recorded by the neurology services and rheumatology fellows.  In comparing the two different EHR systems, more detailed examinations were found with users who free typed examinations versus those who used templated exams.   Conclusions` This study demonstrated the need for optimization of EHR practices with regard to managing patients with arthritic and musculoskeletal conditions.  Several patient cases where joint conditions were key components of the patient care had marked omissions of MSK exam documentation. This may likely reflect a disconnect between what occurs during the examination and what is actually transcribed.  Various factors may foster these oversights including use of templated notes, copy and paste features, and click fatigue.