Background: The costs and limitations of clinical encounter documentation using dictation/transcription have provided impetus for increased use of computerized structured data entry to enforce standardization and improve quality. The purpose of the present study is to compare exam report quality of Veterans Affairs (VA) disability exams documented by computerized protocol-guided templates with exams documented in the usual fashion (dictation).
Methods: Exam report quality for 17,490 VA compensation and pension (C&P) disability exams reviewed in 2005 was compared for exam reports completed by template and exam reports completed in routine fashion (dictation).