Int J Med Inform - The effects of an electronic medical record on the completeness of documentation in the anesthesia record.

Tópicos

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Resumo

JECTIVES: The purpose of this study is to evaluate the completeness of anesthesia recording before and after the introduction of an electronic anesthesia record.METHODS: The study was conducted in a Korean teaching hospital where the EMR was implemented in October 2008. One hundred paper anesthesia records from July to September 2008 and 150 electronic anesthesia records during the same period in 2009 were randomly sampled. Thirty-four essential items were selected out of all the anesthesia items and grouped into automatically transferred items and manual entry items. 1, .5 and 0 points were given for each item of complete entry, incomplete entry and no entry respectively. The completeness of documentation was defined as the sum of the scores. The influencing factors on the completeness of documentation were evaluated in total and by the groups.RESULTS: The average completeness score of the electronic anesthesia records was 3.15% higher than that of the paper records. A multiple regression model showed the type of the anesthesia record was a significant factor on the completeness of anesthesia records in all items (?=.98, p<.05) and automatically transferred items (?=.56, p<.01). The type of the anesthesia records had no influence on the completeness in manual entry items.CONCLUSIONS: The completeness of an anesthesia record was improved after the implementation of the electronic anesthesia record. The reuse of the data from the EMR was the main contributor to the improved completeness.

Resumo Limpo

jectiv purpos studi evalu complet anesthesia record introduct electron anesthesia recordmethod studi conduct korean teach hospit emr implement octob one hundr paper anesthesia record juli septemb electron anesthesia record period random sampl thirtyfour essenti item select anesthesia item group automat transfer item manual entri item point given item complet entri incomplet entri entri respect complet document defin sum score influenc factor complet document evalu total groupsresult averag complet score electron anesthesia record higher paper record multipl regress model show type anesthesia record signific factor complet anesthesia record item p automat transfer item p type anesthesia record influenc complet manual entri itemsconclus complet anesthesia record improv implement electron anesthesia record reus data emr main contributor improv complet

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