A 2024 study of Veterans Affairs outpatient records found significant discrepancies between what patients discussed during visits and what appeared in their electronic health records, according to research published in BMC Primary Care.

In the observational study examining 49 recorded clinical encounters at five Veterans Affairs (VA) primary care clinics, researchers found that most issues patients initiated in discussions were omitted from clinical notes. Additionally, nearly half of the notes contained information or observations that could not be verified in visit transcripts.

The research team, led by Michael Weiner, MD, from the Indiana University School of Medicine, analyzed video recordings of patient visits and compared them with corresponding electronic health record (EHR) documentation. They utilized the Physician Documentation Quality Instrument (PDQI-9) along with 18 additional quality measures.

Key findings included:

• 63% of notes accurately documented patient-initiated issues
• 43% accurately captured clinician-initiated concerns
• 51% included reason for visit
• 76% summarized past medical history
• 65% included medication lists
• 92% contained vital signs
• 74% noted diagnostic test results

The study revealed a notable disparity in documenting psychosocial issues. When clinicians initiated discussion of psychosocial concerns, 92% appeared in notes, but when patients raised psychosocial issues, only 45% were documented in the notes.

Documentation quality scores on the PDQI-9's 5-point scale showed:

• Internal consistency: 4.6
• Comprehensibility: 4.5
• Succinctness: 4.5
• Organization: 4.2
• Synthesis: 4.1
• Accuracy: 4.0
• Thoroughness: 3.7

The study included 11 providers (10 physicians, 1 nurse practitioner) with a mean age of 51 years and an average of 22 years since medical school graduation. The patient population was predominantly male (92%) and Caucasian (82%).

Study limitations included a small sample size, the VA-specific setting, and cross-sectional design. The researchers noted they could not assess how continuity of care relationships might have affected documentation patterns.

The research was funded by the U.S. Department of Veterans Affairs under grant HX002519.