Paper versus electronic documentation in complex chronic illness: a comparison.
作者信息
Smith Catherine Arnott, Haque Saira N
机构信息
School of Information Studies, Syracuse, Syracuse, NY, USA.
出版信息
AMIA Annu Symp Proc. 2006;2006:734-8.
Abstract
This paper reports an analysis and comparison of the electronic and paper medical records of 5 clinically complex persons with spina bifida, who were seen as in- and outpatients at a small Northeastern urban hospital. The combination of chronic illness, multiple medical and allied health specialties, and longer lifespan in this population ensures both a quantitative volume and qualitative complexity of medical event documentation. This ensures a rich field for research into the content and the nature of the fragmented data presently locked in the paper record.
摘要
相似文献
1
Paper versus electronic documentation in complex chronic illness: a comparison.
AMIA Annu Symp Proc. 2006;2006:734-8.
2
A model for documentation of spina bifida.
Paraplegia. 1970 Aug;8(2):82-6. doi: 10.1038/sc.1970.16.
3
Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record.
Am J Emerg Med. 2006 Oct;24(6):664-78. doi: 10.1016/j.ajem.2006.02.005.
4
Mother knows best: medical record management for patients with spina bifida during the transition from pediatric to adult care.
AMIA Annu Symp Proc. 2005;2005:580-4.
5
Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study.
Emerg Med J. 2014 Dec;31(12):980-5. doi: 10.1136/emermed-2013-202479. Epub 2013 Aug 23.
6
7
A comparison of self-documentation in diabetics: electronic versus paper diaries.
AMIA Annu Symp Proc. 2003;2003:887.
8
The effects of an electronic medical record on the completeness of documentation in the anesthesia record.
Int J Med Inform. 2013 Aug;82(8):702-7. doi: 10.1016/j.ijmedinf.2013.04.004. Epub 2013 May 31.
9
Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities.
Int J Med Inform. 2013 May;82(5):313-24. doi: 10.1016/j.ijmedinf.2012.11.011. Epub 2012 Dec 17.
10
Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: an Iranian case study.
Int J Technol Assess Health Care. 2008 Fall;24(4):445-51. doi: 10.1017/S0266462308080586.
引用本文的文献
1
Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.
J Am Med Inform Assoc. 2017 Jan;24(1):140-144. doi: 10.1093/jamia/ocw067. Epub 2016 Jun 29.
2
The role of information system in multiple sclerosis management.
J Res Med Sci. 2014 Dec;19(12):1175-84.
本文引用的文献
1
HL7 Clinical Document Architecture, Release 2.
J Am Med Inform Assoc. 2006 Jan-Feb;13(1):30-9. doi: 10.1197/jamia.M1888. Epub 2005 Oct 12.
2
Parents' psychological adjustment in families of children with spina bifida: a meta-analysis.
BMC Pediatr. 2005 Aug 25;5:32. doi: 10.1186/1471-2431-5-32.
3
Reassessing the methods of medical record review studies in emergency medicine research.
Ann Emerg Med. 2005 Apr;45(4):448-51. doi: 10.1016/j.annemergmed.2004.11.021.
4
Patients' interest in reading their medical record: relation with clinical and sociodemographic characteristics and patients' approach to health care.
Arch Intern Med. 2004 Apr 12;164(7):793-800. doi: 10.1001/archinte.164.7.793.
5
The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems.
Br J Gen Pract. 2003 Dec;53(497):929-33; discussion 933.
6
Effect of XML markup on retrieval of clinical documents.
AMIA Annu Symp Proc. 2003;2003:614-8.
7
Detecting adverse events for patient safety research: a review of current methodologies.
J Biomed Inform. 2003 Feb-Apr;36(1-2):131-43. doi: 10.1016/j.jbi.2003.08.003.
8
Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes.
J Am Med Inform Assoc. 2003 Sep-Oct;10(5):470-7. doi: 10.1197/jamia.M1290. Epub 2003 Jun 4.
9
Resident documentation discrepancies in a neonatal intensive care unit.
Pediatrics. 2003 May;111(5 Pt 1):976-80. doi: 10.1542/peds.111.5.976.
10
Using chart review to screen for medication errors and adverse drug events.
Am J Health Syst Pharm. 2002 Dec 1;59(23):2323-5. doi: 10.1093/ajhp/59.23.2323.
Zotero 插件