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The effects of an electronic medical record on the completeness of documentation in the anesthesia record

Authors
 Junghwa Jang  ;  Seung Hum Yu  ;  Chun-Bae Kim  ;  Youngkyu Moon  ;  Sukil Kim 
Citation
 INTERNATIONAL JOURNAL OF MEDICAL INFORMATICS, Vol.82(8) : 702-707, 2013 
Journal Title
 INTERNATIONAL JOURNAL OF MEDICAL INFORMATICS 
ISSN
 1386-5056 
Issue Date
2013
MeSH
Anesthesia/standards* ; Anesthesia Department, Hospital/standards* ; Documentation/standards* ; Hospital Information Systems/standards* ; Humans ; Medical Records Systems, Computerized/standards*
Keywords
Completeness of documentation ; Electronic anesthesia record ; Electronic medical record
Abstract
OBJECTIVES: 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 (β=.98, p<.05) and automatically transferred items (β=.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.
Full Text
http://www.sciencedirect.com/science/article/pii/S1386505613001007
DOI
10.1016/j.ijmedinf.2013.04.004
Appears in Collections:
1. College of Medicine (의과대학) > Dept. of Preventive Medicine and Public Health (예방의학교실) > 1. Journal Papers
Yonsei Authors
Yu, Seung Hum(유승흠)
URI
https://ir.ymlib.yonsei.ac.kr/handle/22282913/86986
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