Journal List > J Korean Soc Med Inform > v.15(2) > 1035523

Shin, Park, Jung, Noh, and Kim: The Paper-Based Medical Record Compared to the Electronic Medical Record: Documentation and Agreement of Information

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.

Figures and Tables

Table 1
Existence of record according to categories on PMR* and EMR in admission record
jksmi-15-201-i001

*Paper-based medical record

Electronic medical record

Table 2
Level of record on PMR* and EMR in admission record
jksmi-15-201-i002

*Paper-based medical record

Electronic medical record

Table 3
Level of record on PMR* and EMR in doctor's admission note
jksmi-15-201-i003

*Paper-based medical record

Electronic medical record

Table 4
Level of record on PMR* and EMR in admission nursing record
jksmi-15-201-i004

*Paper-based medical record

Electronic medical record

Table 5
Agreement doctor's record and nurse's record on PMR* and EMR in admission record
jksmi-15-201-i005

*Paper-based medical record

Electronic medical record

No record

Notes

This work was supported by the grant No. RTI04-01-01 from the Regional Technology Innovation Program of the Ministry of Knowledge Economy (MKE)

References

1. Park BJ. Availability of medical records in medical research. J Korean Med Assoc. 1994. 37(12):1432–1437.
2. Choi HJ. Core data set from medical record for information sharing between health care institutions (dissertation). 2003. Seoul: Yonsei University.
3. Kim JS. A study on the web-based medical information systems (dissertation). 2003. Muan-gun: Mokpo National University.
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 medical record of system of the EMR (dissertation). 2005. Daejeon: Daejeon University.
6. Seo SW, Kim KH, Kang S, Kang JK, Cho WH, Hong JH, et al. A study on medical laws and external evaluation criteria with reference to the essential forms consisting medical records and to the items for each medical record. J Korean Soc Qual Assur Health Care. 2002. 9(2):176–197.
7. Park SG, Kim HT, Kim KH, Seo SW. Survey of completeness of medical records in one educational hospital 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 factors related to the quality of medical records-focused on physician'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. J Korean Soc Qual Assur Health Care. 1996. 3(2):60–68.
10. Jung MJ. Comparison of documentation completeness between the paper-based medical record and the electronic medical record (dissertation). 2005. Seoul: Yonsei University.
11. Park CH, Lee C, Kim CY. Effect of electronic medical record on quality improvement of psychiatric inpatient medical record. Korean J Psychopathol. 2001. 10(2):118–125.
12. Seo JS. A study on the level of medical record documentation and agreement in the information on the patient's past history (dissertation). 2005. Seoul: Yonsei University.
13. Kaboi PJ. Assessing the accuracy of computerized medication histories. Am J Manag Care. 2004. 10(11):872–877.
TOOLS
Similar articles