Torab-Miandoab Amir, Samad-Soltani Taha, Jodati Ahmadreza, Akbarzadeh Fariborz, Rezaei-Hachesu Peyman
Department of Health Information Technology, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
J Educ Health Promot. 2025 Jul 4;14:246. doi: 10.4103/jehp.jehp_320_24. eCollection 2025.
The introduction of electronic medical records (EMRs) has transformed healthcare documentation practices, offering potential improvements in the quality and efficiency of clinical documentation. As EMR adoption becomes more widespread, there is a growing need to understand its impact on clinical documentation practices. This article addresses this gap by presenting a comprehensive case study that examines the influence of EMRs on clinical documentation within a specific healthcare setting.
The researchers developed an EMR system by using various technologies and implemented it in the VIP department of Shahid Madani Hospital at Tabriz University of Medical Sciences. To ensure successful implementation, comprehensive training was provided to department personnel, and necessary equipment was supplied. The impact of the system on clinical documentation processes was evaluated based on AHIMA data characteristics through a comparison of paper and electronic records. Healthcare provider satisfaction was evaluated using an Electronic Health Record End-User Survey questionnaire. Data analysis was conducted using SPSS and Excel.
The research examined 351 files to assess the effects of introducing EMRs on clinical documentation procedures and user contentment. Findings revealed that EMRs led to an average time saving of 75 minutes in clinical documentation. Moreover, there was a significant enhancement in the quality of documentation, as indicated by the correlation coefficient ( < 0.016). The average system quality score of 4.64 suggested an acceptable level.
High-quality clinical documentation is essential for patient care, and healthcare professionals must strive for the highest standards. While educational campaigns are somewhat effective, the introduction of EMRs significantly improved clinical documentation standards to 100% in all areas. Customizing the EMR to meet end-user needs and utilizing outcome measures will ensure ongoing improvement in clinical documentation standards.
电子病历（EMR）的引入改变了医疗记录方式，有望提高临床记录的质量和效率。随着电子病历的应用越来越广泛，人们越来越需要了解其对临床记录方式的影响。本文通过一个全面的案例研究来填补这一空白，该研究考察了电子病历在特定医疗环境中对临床记录的影响。
研究人员利用多种技术开发了一个电子病历系统，并在大不里士医科大学沙希德·马达尼医院的贵宾部实施。为确保成功实施，为部门人员提供了全面培训，并提供了必要的设备。通过比较纸质记录和电子记录，根据美国健康信息管理协会（AHIMA）的数据特征评估该系统对临床记录过程的影响。使用电子健康记录终端用户调查问卷评估医疗服务提供者的满意度。使用SPSS和Excel进行数据分析。
该研究检查了351份文件，以评估引入电子病历对临床记录程序和用户满意度的影响。研究结果显示，电子病历使临床记录平均节省了75分钟。此外，相关系数表明文档质量有显著提高（<0.016）。平均系统质量得分为4.64，表明处于可接受水平。
高质量临床记录对患者护理至关重要，医疗专业人员必须追求最高标准。虽然教育活动有一定效果，但引入电子病历显著提高了所有领域的临床记录标准，达到了100%。定制电子病历以满足终端用户需求并采用结果指标将确保临床记录标准持续改进。
