BMC health services research
Effect of pre-visit computer-assisted history-taking with a structured copy-ready summary on documentation completeness in screening for inflammatory rheumatic diseases: a randomized pilot study
By Roemer A, Wilhelmi T, Fink D and 8 others.
Abstract
Background
Clinical encounters in outpatient care are constrained by high demand, limited consultation time, and documentation requirements. Computer-assisted history-taking (CAHT) may improve the structured collection of patient information before consultations and disease screening, but evidence is limited. This randomized pilot study evaluated whether pre-visit CAHT combined with a copy-ready summary increased documentation completeness and assessed patient and physician acceptance.
