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Recorded vignettes: a novel method for investigating documentation in the Electronic Healthcare Record (EHR)

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posted on 2023-06-08, 22:35 authored by Simon Glew, Helen Smith
Background: 360 million consultations documented annually in England1 Accurate descriptors required for secondary data functions: Computerised decision support; Financial reimbursement; Audit; Disease prevalence monitoring and research Coding is not explicitly taught within the GP curriculum How do you research how clinicians document? Previous studies: use real patients2/actors3 interacting with clinician studied; Lack standardisation; Expensive. Why Allergy? Growing clinical problem; 2014 NICE guidelines4: Poor clinical documentation is a major issue in allergy; EHR can’t distinguish between intolerance and allergy; Incorrect labelling of patients; Adverse impact on patient care? Little known about coding practices in non-incentivised condition such as allergy. Method: A novel method developed to standardize research of EHR use. Filmed 6 short vignettes (21-50 secs) Monologue of common allergic presentations as if in consultation with a doctor. Digital photographs were included to replicate rashes. Electronic distribution of study files Documented vignettes in their own EHR Returned screen-prints to the researcher for analysis - Codes, free text and EHR functions Questionnaire - Exploring decision-making and validation of method Initially piloted on 1 GP and 2 trainees leading to refinements. Results 7 GPs and 15 GP trainees were recruited All successfully completed Data was returned from 4 different EHRs SystmOne (6), EmisLV (2), EmisWeb (6) and Vision (8) Screen prints effectively captured data with minor technical difficulties reported by 2 participants The study took 1 - 2 hours to complete: longer than expected from the pilot study.

History

Publication status

  • Published

File Version

  • Published version

Event name

Royal College of General Practitioners (RCGP) Annual Conference 2015

Event location

SECC, Glasgow, Scotland, UK

Event type

conference

Event date

1-3 October 2015

Department affiliated with

  • BSMS Publications

Full text available

  • Yes

Peer reviewed?

  • Yes

Legacy Posted Date

2015-10-16

First Open Access (FOA) Date

2015-10-16

First Compliant Deposit (FCD) Date

2015-10-15

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