To evaluate quantitative and qualitative differences in documentation of the ophthalmic examination between paper and electronic health record (EHR) systems.
We analyzed differences in procedure documentation between the PDA form and handwritten index cards based on the 20 procedures that were present on both platforms.
Differences in documentation were compared using Wilcoxon test for continuous variables and Chi for categorical variables.
Although it is conceivable that complications of IMD may be dependent on specific interactions between the host and the pathogen, including the serogroup of the isolate, they could also be explained by differences in documentation in the 2 studies.
Differences in microbiological documentation make comparisons between ICUs difficult to interpret.
Table 2 shows the differences in triage documentation when measured by AAACN documentation criteria and by triage document content.
Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued.
The only noteworthy difference in the documentation is that the operator of a LinkedHashMap is currently read-only; it cannot be used for insertion.
In the case of written information, differences in QI score between hospitals could have been due to different documentation processes rather than to genuine lack of information and/or cooperation between healthcare providers.
To our knowledge, this is the first study to quantify these differences in telephone triage documentation attributable to CDS.
