The Impact of Documentation Workflow on the Accuracy of the Coded Diagnoses in the Electronic Health Record
Thomas S. Hwang, Merina Thomas, Michelle R. Hribar, Aiyin Chen, Elizabeth White
Abstract
ObjectiveTo determine the impact of documentation workflow on the accuracy of coded diagnoses in the electronic health recordsDesignThis cross-sectional study assessed the rate of agreement between the diagnoses in the clinical notes and the coded diagnosis in the electronic health record using manual review and examined the impact of the documentation workflow on the rate of agreement in an academic retina practiceParticipantsAll patients with completed visits at the Casey Eye Institute Retina Division faculty clinic between 4/7/22 and 4/13/22Main OutcomesAgreement between coded diagnoses and clinical notesResultsIn 202 visits by 8 physicians, 78% (range 22-100%) had an agreement between the coded diagnoses and the clinical notes. When physicians integrated the diagnosis code entry and note composition, the rate of agreement was 87.9% (range 62-100%). For those that entered the diagnosis codes separately from writing notes, the agreement was 44.4% (22-50%, p < 0.0001).ConclusionThe visit-specific agreement between the coded diagnosis and the progress note can vary widely by workflow. The workflow and electronic health record design may be an important part of understanding and improving the quality of electronic health record data.