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Tuepker A, Zickmund SL, Nicolajski CE, Hahm B, Butler J, Weir C, Post L, Hickam DH. Providers' Note-Writing Practices for Post-traumatic Stress Disorder at Five United States Veterans Affairs Facilities. J Behav Health Serv Res 2018; 43:428-42. [PMID: 26228929 DOI: 10.1007/s11414-015-9472-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The capacity of electronic health records (EHRs) to capture desired information depends on the practices of health care providers. These practices have not been well studied in relation to post-traumatic stress disorder (PTSD). This qualitative study investigated how providers write EHR notes on PTSD through 38 interviews with providers working at five Veterans Affairs (VA) hospitals across the United States of America. Two overarching themes were prominent in the results. Providers used progress notes primarily to remember and access details for direct patient care, but only rarely for care coordination. Providers infrequently recorded information not judged to directly contribute to improved care, sometimes deliberately omitting information perceived to jeopardize patients' access to, or quality of, care. Omitted information frequently included sexual or non-military trauma. Understanding providers' thought processes can help clinicians be aware of the limitations of EHR notes as a tool for learning the histories of new patients. Similarly, researchers relying on EHR data for PTSD research should be aware of likely areas of missing data.
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Affiliation(s)
- Anaïs Tuepker
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA. .,Division of General Internal Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Susan L Zickmund
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Bridget Hahm
- James A. Haley Veterans Hospital, Tampa, FL, USA
| | - Jorie Butler
- Consortium for Healthcare Informatics Research, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Charlene Weir
- Consortium for Healthcare Informatics Research, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Lori Post
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - David H Hickam
- Patient Centered Outcomes Research Institute (PCORI), Washington, DC, USA
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