Journal of Korean Society of Medical Informatics  2009;15(2):201-208

doi:10.4258/jksmi.2009.15.2.201

The Paper-Based Medical Record Compared to the Electronic Medical Record: Documentation and Agreement of Information.

A Mi SHIN 1 ; Hee Joon PARK ; Sun Ju JUNG ; Mi Jin NOH ; Yoon Nyun KIM

Affiliations

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Keywords

Medical Record; Hospital Information System; Evaluation

Country

Republic of Korea

Language

Korean

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.