원저 : 종이의무기록과 전자의무기록의 기재 충실도 및 일치도 비교 연구: 의사의 입원,퇴원기록지와 간호사의 입원,퇴원간호정보기록지를 중심으로

Abstract

This study was tried to evaluate the level of completeness and the accordance in electronic medical records by comparing paper-based medical record in doctor`s admission records, discharge summary, and nursing information records. Medical records of inpatients of neurology department that the 100 paper-based medical records in 2004 and 100 electronic medical records in 2006 were targeted. Existence of record items and doctor-nurse record accordance were evaluated in doctor`s admission record, discharge summary, admission nursing information record, and discharge nursing information record. There were not any differences between electronic medical records and paper-based medical records in doctor`s admission record and discharge summary. Electronic medical records had less missing records than paper-based medical records in admission and discharge nursing information records. Electronic medical records showed higher accordance than the paper-based medical record in doctor-nurse record generally, but there were statistically differences in only medication, allergy, smoking, and drinking(p<0.05). In this study, it was verified that the quality of electronic medical records are better than paper-based records in nursing information record and doctor-nurse record agreement.