Patient survey data contradicting electronic medical records (EMR) shows a potential path to errors and problematic care. A study, published in JAMA Ophthalmology, examines the inconsistency of eye symptoms reported in a patient survey versus EMRs.
Keeping information accurate and consistent is crucial in providing quality care to patients. This study examined the differences in symptom reporting in EMRs and a patient self-reporting in an Eye Symptom Questionnaire (ESQ). Analyzing 162 patients in the Kellogg Eye Center, researchers reviewed differenced in patient ESQs and EMRs.
- 33.8 percent differences in reporting blurry vision form EMR and ESQ.
- 48.1 percent difference in reporting glare.
- 26.5 percent difference in reporting pain or discomfort.
- 24.7 percent difference in redness.
- Researchers noted more self-reporting to the ESQ while there was a lack of documentation in the EMR.
- Patients who had reported blurry vision had increased rates of not reporting they symptom again on a return visit.
“This study identifies a key challenge for an EMR system, namely, the quality of the documentation,” concluded Nita G. Valikodath, MS, the first author on the study and colleagues. “We found significant inconsistencies between symptom self-report on an ESQ and documentation in the EMR, with a bias toward reporting more symptoms via self-report. If the EMR lacks relevant symptom information, it has implications for patient care, including communication errors and poor representation of the patient’s reported problems. The inconsistencies imply caution for the use of EMR data in research studies. Future work should further examine why information is inconsistently reported. Perhaps the implementation of self-report questionnaires for symptoms in the clinical setting will mitigate the limitations of the EMR and improve the quality of documentation.”