Electronic Health Record Documentation Times among Emergency Medicine Trainees.

Abstract

Physicians spend a large portion of their time documenting patient encounters using electronic health records (EHRs). Meaningful Use guidelines have made EHR systems widespread, but they have not been shown to save time. This study compared the time required to complete an emergency department note in two different EHR systems for three separate video-recorded standardized simulated patient encounters. The total time needed to complete documentation, including the time to write and order the initial history, physical exam, and diagnostic studies, and the time to provide medical decision making and disposition, were recorded and compared by trainee across training levels. The only significant difference in documentation time was by classification, with second- and third-year trainees being significantly faster in documenting on the Cerner system than fourth-year medical student and first-year trainees (F = 8.36, p < .001). Level of training and experience with a system affected documentation time.