Electronic Medical Records (EMR) over manual documentation of in-patient records: a scientific insight
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Abstract
Background: Patient Medical Records are crucial for the track of healthcare rendered and appropriateness of the treatment provided to the patient. With the increased adoption of NABH and JCI standards in hospitals, documentation of medical records has become a mandatory process. The study focuses on the efficiency of the manual documentation system.
Methods: The complete list of documents (forms & formats) filed under patient medical records were identified through observational research in the medical records department. The study involved a sample survey method with the help of a questionnaire that includes probability random sampling of size 261. The statistical tools used were chi-square analysis, ANOVA, and correlation.
Results: The chi-square analysis describes the reliability of the documentation system affected by legibility and completeness of the medical records. The ANOVA test inferred that the overall opinion of employees on the documentation system varies depending on their designation. The analysis for correlation describes that an increase in medication errors increases the time taken for processing of medication to the patient. The Pareto analysis for the problems due to manual documentation describes 80% of the problem is raised by 20% of the causes, namely “time-consuming process” and “legibility of the patient records.” Common suggestions from the employees were the implementation of electronic medical records.
Conclusion: The study results suggest that it was to either implement integrated electronic medical records or partially automate the supportive documents apart from the point of care records.
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