1. Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients
- Author
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Elton R Edwards, Filip Cosic, Chris Witkowski, and Lara A Kimmel
- Subjects
medicine.medical_specialty ,business.industry ,Health Policy ,Medical record ,media_common.quotation_subject ,Australia ,MEDLINE ,Documentation ,medicine.disease ,Hospitals ,Cohort ,Orthopedic surgery ,Operative report ,Electronic Health Records ,Humans ,Medicine ,Quality (business) ,Medical emergency ,Electronics ,business ,Orthopaedic trauma ,media_common - Abstract
Objective The medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR). Methods A review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery. Results In all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P
- Published
- 2021