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KMID : 0926620100150010001
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Korean Journal of Hospital Management
2010 Volume.15 No. 1 p.1 ~ p.12
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A Study of Comparing the Paper-Based Medical Record with the Electronic Medical Record on the Level of Medical Record Completeness and the Accordance
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Shin A-Mi
Park Hee-Joon
Youn Kyung-Il
Kim Youn-Nyun
Son Chang-Sik
Jung Sun-Ju
Lee In-Hee
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Abstract
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This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor’s admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor’s admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor’s admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking(p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.
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KEYWORD
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Paper-based medical record, Electronic medical record, Completeness, Accordance
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