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

Journal of Korean Society of Medical Informatics Pub Date : 2009-06-01 DOI:10.4258/JKSMI.2009.15.2.201

A. Shin, Hee-Joon Park, Sun-Ju Jung, M. Noh, Yoon Nyun Kim

{"title":"The Paper-Based Medical Record Compared to the Electronic Medical Record: Documentation and Agreement of Information","authors":"A. Shin, Hee-Joon Park, Sun-Ju Jung, M. Noh, Yoon Nyun Kim","doi":"10.4258/JKSMI.2009.15.2.201","DOIUrl":null,"url":null,"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.","PeriodicalId":255087,"journal":{"name":"Journal of Korean Society of Medical Informatics","volume":"30 1","pages":"0"},"PeriodicalIF":0.0000,"publicationDate":"2009-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"3","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Korean Society of Medical Informatics","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.4258/JKSMI.2009.15.2.201","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}

引用次数: 3

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.

查看原文本刊更多论文

纸质病历与电子病历的比较:文档化与信息协议

目的:本研究旨在评价电子病历与纸质病历的质量和一致性。方法:收集2004年纸质病历和2007年电子病历中动脉颤动住院患者的数据。评估类别包括主诉、现病史、既往病史、用药史、住院史、家族史、过敏史、吸烟史、住院记录中的饮酒史。结果:电子病历在病历存在性、病历信息水平和信息一致性方面得分较高。然而，医生和护士提供的信息存在一些类别的不一致，还有一些类别没有医生或护士的记录。结论:本研究结果证实了电子病历在记录的存在性、信息的水平和一致性方面优于纸质病历。但是，这两种记录所包含的信息存在差异。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文求助全文

来源期刊

Journal of Korean Society of Medical Informatics

自引率

0.00%

发文量