Clinical Documentation Before and After Implementing an EMR - An Empirical Study

Author: Fanny Hawkins

Primary Advisor:

Committee Members:

Masters thesis, The University of Texas School of Health Information Sciences at Houston.

This paper reviews current clinical data documentation requirements for medical records, and presents an empirical study comparing the presence or absence of clinical data before and after implementing an EMR. The general documentation requirements used in this empirical study include recommendations for medical record content from the NCQA, the JCAHO, and the Medicare Conditions of Participation. The documentation requirements were reviewed in six major categories: Patient identification present, Summary page content complete, Signatures present, Dictated reports present, Immunization records present and complete, Lab reports filed correctly and signed. The Fisher Exact Probability test was to analyze the data for significance. In the post EMR chart review, of the twenty four Fisher Exact test performed, 4 were significant at the .05 level, and 13 were significant at the .001 level.