Table 2 Measures for “improved inpatient EHR documentation” and their definitions
Outcome measure | Definition |
|---|---|
Medication accuracy | The absence of or decline in the number of errors and discrepancies present in the medication record |
Document accuracy | The absence of or decline in the number of errors and discrepancies present in the EHR document |
Completeness | The lack or decrease of missing information, as well as the addition of documented items within a medical record |
Timeliness | A decrease in the time required to complete the document and also a shortening of the turnaround time necessary for the document to be available |
Overall quality | Variously defined by each study and assessed through mean scores of personalized checklists or quality indicators |
Clarity | A well-organized, readable, and easily understandable document |
Length | The decrease in the number of lines or word count |
Document capture | An increased number of documents created (not included in this review because of lack of data) |
User satisfaction | Determined by the primary EHR users in surveys that evaluate their opinion on the implementation of the intervention |