College of Public Health and Health Informatics (CPHHI), King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), Riyadh, Kingdom of Saudi Arabia.
College of Medicine, The University of Sharjah, Sharjah, United Arab Emirates.
J Med Syst. 2017 Nov 4;41(12):199. doi: 10.1007/s10916-017-0826-0.
Certain Saudi healthcare organizations transfer outpatients to medical imaging departments for radiological examinations in a manual process that relies on the use of paper-based forms. With the increased implementation of electronic medical records in Saudi Hospitals, little is known about the completeness and legibility of information captured in electronic-based medical imaging forms. The purpose of this study is to audit the completeness and legibility of medical imaging paper-based forms in comparison with electronic-based medical imaging forms. As a secondary objective, we also examined the number of errors found on the forms.An observational retrospective cross-sectional study was utilized to audit the completeness and legibility of both paper and electronic forms collected between March 1 and May 15, 2015. The study measured the association among categorical variables using Chi-Square analysis. The results of this investigation show a significant association between form completion and type of record (i.e., paper vs. electronic) where electronic-based systems were found to be more complete than paper-based records. Electrnoic based records were also found to improve form legibility, promote user adherence to complete the forms and minimize entry errors. In conclusion, electronic-based medical imaging forms are more complete and legible than paper based forms. Future studies should evaluate other hospitals and compare both legibility and completeness of electronic-based medical imaging forms and conduct usability evaluation studies with users to explore the impacts of system design on both completeness and legibility of electronic forms, in general, but more specifically, electronic-based medical imaging forms.
某些沙特医疗机构在将门诊患者转至放射科进行影像学检查时，采用手工流程，依赖纸质表格。随着电子病历在沙特医院中的广泛应用，对于电子医学影像表单中所捕获信息的完整性和清晰度知之甚少。本研究旨在对比纸质医学影像表单和电子医学影像表单，审核其信息的完整性和清晰度。作为次要目标，我们还检查了表单上发现的错误数量。本研究采用观察性回顾性横断面研究方法，审核了 2015 年 3 月 1 日至 5 月 15 日期间收集的纸质和电子表单的完整性和清晰度。研究使用卡方分析来衡量分类变量之间的关联。调查结果表明，表单的完整性与记录类型（即纸质与电子）之间存在显著关联，电子系统比纸质记录更为完整。电子记录还提高了表单的清晰度，促进了用户填写表单的依从性，并最大限度地减少了录入错误。总之，电子医学影像表单比纸质表单更完整、更清晰。未来的研究应评估其他医院，并比较电子医学影像表单的清晰度和完整性，同时与用户进行可用性评估研究，以探索系统设计对电子表单的完整性和清晰度的影响，尤其是电子医学影像表单。
