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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