Hippisley-Cox Julia, Pringle Mike, Cater Ruth, Wynn Alison, Hammersley Vicky, Coupland Carol, Hapgood Rhydian, Horsfield Peter, Teasdale Sheila, Johnson Christine
Division of General Practice, Nottingham University, Nottingham NG7 2RD.
BMJ. 2003 Jun 28;326(7404):1439-43. doi: 10.1136/bmj.326.7404.1439.
To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve.
Cross sectional study with review of medical records and interviews with general practitioners.
25 general practices in Trent region.
53 British general practitioners (25 using paperless records and 28 using paper based records) who each provided records of 10 consultations.
Content of a sample of records and doctor recall of consultations for which paperless or paper based records had been made.
Compared with paper based records, more paperless records were fully understandable (89.2% v 69.9%, P=0.0001) and fully legible (100% v 64.3%, P < 0.0001). Paperless records were significantly more likely to have at least one diagnosis recorded (48.2% v 33.2%, P=0.05), to record that advice had been given (23.7% vs 10.7%, P=0.017), and, when a referral had been made, were more likely to contain details of the specialty (77.4% v 59.5%, P=0.03). When a prescription had been issued, paperless records were more likely to specify the drug dose (86.6% v 66.2%, P=0.005). Paperless records contained significantly more words, abbreviations, and symbols (P < 0.01 for all). At doctor interview, there was no difference between the groups for the proportion of patients or consultations that could be recalled. Doctors using paperless records were able to recall more advice given to patients (38.6% v 26.8%, P=0.03).
We found no evidence to support our hypotheses that paperless records would be truncated and contain more local abbreviations; and that the absence of writing would decrease subsequent recall. Conversely we found that the paperless records compared favourably with manual records.
确定无纸化病历所含信息是否少于纸质病历，以及这些信息是否更难检索。
通过查阅病历及采访全科医生进行横断面研究。
特伦特地区的25家全科诊所。
53名英国全科医生（25名使用无纸化病历，28名使用纸质病历），每人提供10次会诊记录。
记录样本的内容以及医生对已制作无纸化或纸质病历的会诊的回忆。
与纸质病历相比，更多无纸化病历完全可理解（89.2%对69.9%，P=0.0001）且完全清晰可读（100%对64.3%，P<0.0001）。无纸化病历更有可能至少记录一项诊断（48.2%对33.2%，P=0.05），记录已给出的建议（23.7%对10.7%，P=0.017），并且在进行转诊时，更有可能包含专科细节（77.4%对59.5%，P=0.03）。开具处方时，无纸化病历更有可能明确药物剂量（86.6%对66.2%，P=0.005）。无纸化病历包含的单词、缩写和符号明显更多（所有P<0.01）。在医生访谈中，两组能够回忆起的患者或会诊比例没有差异。使用无纸化病历的医生能够回忆起更多给予患者的建议（38.6%对26.8%，P=0.03）。
我们没有发现证据支持以下假设：无纸化病历会被删减且包含更多当地缩写；以及没有书写会降低后续回忆。相反，我们发现无纸化病历与手工记录相比具有优势。
