LTC facilities that have adopted EHRs experience improvements in quality of care, documentation access, billing and reimbursement, and employee satisfaction and retention rates.
Assessing change in practice by assessing documentation of the Ottawa ankle rules in the case notes was hampered by inconsistencies in the quality of documentation.
Over the course of the study, there was no difference in perceived quality of documentation with SR compared to overall technology (p = 0.375).
To examine whether the improvement in the quality of documentation was simply a result of the presence of the intervention team (a Hawthorne effect) we analysed the quality of documentation in relation to PAR use in the post-intervention period only.
In addition, the quality of documentation on discharge summaries was poor, resulting in missed test results 33-633 %), inadequate treatment or hospital course details (7-22 %), non-provision of discharge medications (2-40 %), no test results pending at discharge (65%%), no patient or family counselling 90-922 %) and no follow up plans (2-432-43% 12].
Although comparing GDL and GELLO thoroughly is beyond the scope of this study, the following could be possible points of comparison for future research: expressiveness for CDS purposes, availability of tools and development environments for the two CDS languages, wealth of experiences in their use, quality of documentation and accessibility.
Delivery of other interventions recommended in guidelines was often low (see Table 4) and the quality of documentation in the health record regarding the intervention and follow up management plan was often poor and incomplete.
Our study demonstrates that a standardised surgical clerking proformas improves the quantity and quality of documentation in comparison to freehand clerking, is preferred by health professionals and improves reliability of the audit quality control process.
Second, the accuracy of measures is dependent on the quality of documentation in the patient record.
The authors used the quality of documentation in the maternity record as a proxy indicator for the quality of care.
