Table 2.
Comparison of Completeness of Documentation and Appropriateness of Medical Decisions Made, Between Providers Who Used Computer-based Patient Records (CPRs) and Those Who Used Paper Records
Rating Dimension | n | CPR Users (Mean)/Highest Possible Score | Paper-Record Users (Mean)/Highest Possible Score | Significance |
---|---|---|---|---|
Major problems documented in problem list | 169 | 1.79/2.00 | 0.93/2.00 | <0.001 |
Medications documented in medication list | 171 | 1.75/2.00 | 0.91/2.00 | <0.001 |
Allergies documented in mini-record | 169 | 1.97/2.00 | 1.85/2.00 | 0.07 |
Relevant clinical factors considered in assessment and plan | 172 | 1.53/2.00 | 1.07/2.00 | <0.001 |
Appropriateness of assessment and plan | 172 | 3.63/5.00 | 2.50/5.00 | <0.001 |