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Electronic health record reviews to measure diagnostic uncertainty in primary care.

Viraj BhiseSuja S RajanDean F SittigViralkumar VaghaniRobert O MorganArushi KhannaHardeep Singh
Published in: Journal of evaluation in clinical practice (2018)
While current diagnosis coding mechanisms (ICD-9 and ICD-10) are unable to capture uncertainty, our study finds that review of EHR documentation can help identify diagnostic uncertainty with moderate reliability. Better measurement and understanding of diagnostic uncertainty could help inform strategies to improve the safety and efficiency of diagnosis.
Keyphrases
  • electronic health record
  • primary care
  • clinical decision support
  • adverse drug
  • randomized controlled trial
  • high intensity
  • general practice