A comparison of electronic records to paper records in mental health centers.

OBJECTIVE

Medication documentation is a critical aspect of quality patient care. The current study examined whether electronic medical records provide medication documentation that is more complete and faster to retrieve than traditional paper records.

METHOD

This study involves a comparison of archived paper medical records to recent electronic medical records through chart review. A convenient sample of three large community mental health centers in Indiana was used. Medical charts for 180 patients with schizophrenia were rated on a checklist composed of 16 items that was adapted from a national project. Documentation that existed before implementation of the electronic medical record system was compared with that after implementation at each of the three centers. The main outcome measures were completeness and retrieval time of medication documentation.

RESULTS

Electronic medical records provided medication documentation that was more complete and faster to retrieve than paper records across all centers and within each center. On average, electronic medical records were 40% more complete and 20% faster to retrieve.

CONCLUSION

Electronic records have potential to improve medication management for patients in mental health centers over traditional records. However, medication documentation for patients diagnosed with schizophrenia was found to be deficient in many areas, regardless of documentation format.