Korea Journal of Hospital Management (한국병원경영학회지)

Korean Society of Hospital Management (한국병원경영학회)
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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

종이의무기록과 전자의무기록의 기재 충실도 및 일치도 비교 연구 : 의사의 입원.퇴원기록지와 간호사의 입원.퇴원간호정보기록지를 중심으로

  • Shin, A-Mi (Department of Medical Informatics, School of Medicine Keimyung University) ;
  • Jung, Sun-Ju (Biomedical Information Technology Center, Keimyung University) ;
  • Lee, In-Hee (Department of Medical Informatics, School of Medicine Keimyung University) ;
  • Son, Chang-Sic (Biomedical Information Technology Center, Keimyung University) ;
  • Park, Hee-Joon (Department of Medical Informatics, School of Medicine Keimyung University) ;
  • Kim, Yoon-Nyun (Department of Medical Informatics, School of Medicine Keimyung University) ;
  • Youn, Kyung-Il (Department of Medical Informatics, School of Medicine Keimyung University)
  • 신아미 (계명대학교 의과대학 의료정보학교실) ;
  • 정선주 (계명대학교 생체정보기술개발사업단) ;
  • 이인희 (계명대학교 의과대학 의료정보학교실) ;
  • 손창식 (계명대학교 생체정보기술개발사업단) ;
  • 박희준 (계명대학교 의과대학 의료정보학교실) ;
  • 김윤년 (계명대학교 의과대학 의료정보학교실) ;
  • 윤경일 (계명대학교 의과대학 의료정보학교실)
  • Received : 2010.01.06
  • Accepted : 2010.02.23
  • Published : 2010.03.30
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Abstract

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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