Electronic Health Records (EHRs) can be used for research but this raises the problem of data quality.
Objective: To evaluate the quality of the information recorded in an EHR by a general practitioner (GP) during a regular office consultation.
Method: 191 dialogs between the GP and patient were recorded and translated into the International Classification of Primary Care Second edition (ICPC-2) codes. Written information of the corresponding EHR was extracted and coded for comparison.
Results: The primary reason for the consultation was recorded in the EHR in 41.2% of the cases and the diagnosis in 44.1% of the cases. Diagnoses noted in the EHR were less often communicated to the patients than the primary reasons (p<0.0001).
Conclusion: There is a loss of information between the dialog during a consultation and what is reported in the EHR. Consequences in terms of continuity and safety of care can be expected.
Keywords: Electronic Health Records; Information Management; Self Report.