Healthcare Informatics Research

Korean Society of Medical Infomatics (대한의료정보학회)
권호 표지

The Paper-Based Medical Record Compared to the Electronic Medical Record: Documentation and Agreement of Information

종이의무기록과 전자의무기록의 기재정도 및 일치도 비교 연구: 심방세동 환자 입원기록을 중심으로

Shin, A-Mi;Park, Hee-Joon;Jung, Sun-Ju;Noh, Mi-Jin;Kim, Yoon-Nyun
신아미;박희준;정선주;노미진;김윤년

  • Published : 20090600
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Abstract

Objective: This aim of this study was to evaluate the quality and agreement of electronic medical records with paper-based medical records. Methods: Data was collected from the paper-based medical records generated during 2004 and electronic medical records during 2007, in patients hospitalized for arterial fibrillation. The categories evaluated included the chief complaint, history of present illness, past illness, medication history, admission history, family history, allergies, smoking history, and drinking history in admission record. Results: The electronic medical records scored higher for: the existence of a medical record, level of information in the medical record and agreement of information. However, there were some categories of disagreement between the information from doctors and nurses, and there were several categories with no record by doctors or nurses. Conclusion: The results of this study confirmed that the quality of the electronic medical record is better than that of paper-based medical with regard to: the existence of the record, level and agreement of information. However, there are discrepancies in the information contained within both types of records.

Keywords

References

  1. Park BJ. Availability of medical records in medicalresearch. J Korean Med Assoc 1994;37(12):1432-1437
  2. Choi HJ. Core data set from medical record forinformation sharing between health care institutions(dissertation). Seoul:Yonsei University;2003
  3. Kim JS. A study on the web-based medical informationsystems (dissertation). Muan-gun:Mokpo National University;2003
  4. Hammond KW, Helbig ST, Benson CC, Brathwaite-Sketoe Bm. Are electronic medical record trustworth?Observations on copying, pasting and duplication. AHIMA Annu Symp Proc 2003;269-273
  5. Chung YJ. A study of the completeness of medicalrecord of system of the EMR (dissertation). Daejeon:Daejeon University;2005
  6. Seo SW, Kim KH, Kang S, Kang JK, Cho WH, HongJH, et al. A study on medical laws and externalevaluation criteria with reference to the essential formsconsisting medical records and to the items for eachmedical record. J Korean Soc Qual Assur Health Care2002;9(2):176-197
  7. Park SG, Kim HT, Kim KH, Seo SW. Survey ofcompleteness of medical records in one educationalhospital using new checklist. J Korean Soc Qual Assur Health Care 1997;4(2):174-783
  8. Hong JH, Choi KS, Lee EM. A study on the factorsrelated to the quality of medical records-focused onphysician's commitment. J Korean Soc Qual Assur Health Care 1996;5(1):16-26
  9. Park UJ, Park EW. Predictability of the completeness of medical recording of quality of care for inpatients. JKorean Soc Qual Assur Health Care 1996;3(2):60-68
  10. Jung MJ. Comparison of documentation completenessbetween the paper-based medical record and theelectronic medical record (dissertation). Seoul:Yonsei University;2005
  11. Park CH, Lee C, Kim CY. Effect of electronic medicalrecord on quality improvement of psychiatric inpatientmedical record. Korean J Psychopathol 2001;10(2):118-125
  12. Seo JS. A study on the level of medical recorddocumentation and agreement in the information on thepatient's past history (dissertation). Seoul:Yonsei University;2005
  13. Kaboi PJ. Assessing the accuracy of computerizedmedication histories. Am J Manag Care 2004;10(11):872-877