Objective:

American College of Graduate Medical Education (ACGME) recommends ongoing care of 10 patients per resident however its implication is unclear. We hypothesized EMR quality to vary based on patient load and call status.

Methods:

We conducted a double-blind, single-center, retrospective observational study between 2017 and 2019 to investigate the quality and accuracy of resident documentation using the Responsible Electronic Documentation (RED) Checklist, a validated scoring system.

Results:

A total of 234 independent charts were analyzed and 80 met scoring criteria. Average patients per residents was 4, 9.1, 7.2, and 5.5 on “call” day (D0), “post-call” day (D1), “mid-call” day (D2), and “pre-call” day (D3), respectively. Mean RED checklist scores were 68.1%, 57%, 68.6%, and 72.1% on the above call status. The difference in score between D3 and D1 was statistically significant (P = .00042). There was a negative correlation between score and number of patients per resident (r = −0.286, P = .010).

Conclusion:

EMR documentation quality is directly impacted by patient load and resident call status with the lowest documentation quality on post-call day, correlating with patient load.

中文翻译：

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患者负荷对电子病历文档质量的影响

客观的：

美国研究生医学教育学院 (ACGME) 建议对每位住院医师 10 名患者进行持续护理，但其含义尚不清楚。我们假设 EMR 质量会因患者负荷和呼叫状态而异。

方法：

我们在 2017 年至 2019 年期间进行了一项双盲、单中心、回顾性观察研究，以使用经过验证的评分系统负责任电子文档 (RED) 清单调查居民文档的质量和准确性。

结果：

共分析了 234 个独立图表，其中 80 个符合评分标准。在“呼叫”日（D0）、“呼叫后”日（D1）、“呼叫中”日（D2）和“呼叫前”日，每位居民的平均患者为 4、9.1、7.2 和 5.5 人（ D3），分别。上述呼叫状态的平均 RED 检查表分数分别为 68.1%、57%、68.6% 和 72.1%。D3 和​​ D1 之间的得分差异具有统计学意义 ( P  = .00042)。得分与每位居民的患者数量呈负相关（r  = -0.286，P  = .010）。

结论：

EMR 文档质量直接受到患者负荷和住院呼叫状态的影响，呼叫后一天的文档质量最低，与患者负荷相关。