Tsai Jack, Bond Gary
Department of Psychology, Indiana University-Purdue University Indianapolis, Indiana, USA.
Int J Qual Health Care. 2008 Apr;20(2):136-43. doi: 10.1093/intqhc/mzm064. Epub 2007 Dec 12.
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.
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.
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.
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.
用药记录是优质患者护理的关键环节。本研究探讨电子病历提供的用药记录是否比传统纸质记录更完整且检索速度更快。
本研究通过病历审查，对存档的纸质病历与近期的电子病历进行比较。选取了印第安纳州三个大型社区心理健康中心作为便利样本。根据一项全国性项目改编的包含16项内容的清单，对180例精神分裂症患者的病历进行评分。比较了三个中心在实施电子病历系统之前和之后的记录情况。主要结局指标为用药记录的完整性和检索时间。
在所有中心以及每个中心内部，电子病历提供的用药记录都比纸质记录更完整且检索速度更快。平均而言，电子病历的完整性高出40%，检索速度快20%。
与传统记录相比，电子记录有潜力改善心理健康中心患者的用药管理。然而，无论记录格式如何，被诊断为精神分裂症患者的用药记录在许多方面都存在不足。
