Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior

Key Points Question How closely does documentation in electronic health records match the review of systems and physical examination performed by emergency physicians? Findings In this case series of 9 licensed emergency physician trainees and 12 observers of 180 patient encounters, 38.5% of the review of systems groups and 53.2% of the physical examination systems documented in the electronic health record were corroborated by direct audiovisual or reviewed audio observation. Meaning These findings raise the possibility that some physician documentation may not accurately represent actions taken, but further research is needed to assess this in more detail.