Issue brief 18 - Documenting diagnosis: Exploring the impact of electronic health records on diagnostic safety (AHRQ, August 2024)

Summary

Electronic health records (EHRs) are now used for many functions in healthcare beyond simply record keeping. For healthcare professionals, the EHR is a central platform for pulling together, organising and visualising diagnostic information. It helps with clinical reasoning, record management and communication between the care team. 

This issue brief by the Agency for Healthcare Research and Quality (AHRQ) reviews the history of EHR documentation legislation, including rules and regulations, and outstanding challenges and best practices to improve documentation. It also identifies future developments and opportunities for improvement, including emerging technology-based strategies to improve the traditional documentation process.