Influence of Implementation of Electronic Medical Record System on Medical Record Quality and Cause Analysis

Objective. To study the influence of implementation of the system of electronic medical records on the quality of medical records. Method. Medical record defect rates of 15 clinical departments are chosen according to regular inspection of medical records of the whole hospital by quality control physicians. The defect rates of medical record quality during the four years before and after the implementation of electronic medical records are analyzed by repeatedly using the measurement analysis method of SAS software. Result. The overall medical record defect rates in the initial stage of implementation of electronic medical records increase, which are caused by the following five influencing factors: (1) the medical records are written by intern doctors or training doctors who come to our hospital; (2) the doctors do not develop the habit of printing medical records and signing them immediately, and the defects of absent signature account for 28.5% of the medical record defect rates of 2012; (3) the mandatory items are not filled in the medical records, which account for 22.1% of the medical record defect rates of 2012; the defects in (2) and (3) hardly occur before the implementation of electronic medical records; (4) medical record defects are fully exposed in electronic medical records and are liable to be identified during quality control, the intrinsic defect rate of medical records in 2012 accounts for 13.4% of medical record defect rates, the modification rates only account for 8.3% and 6.5% compared with the situations in 2010 and 2009 before the implementation of electronic medical records; (5) as quality control physicians improve their qualification constantly and widen their quality control range, the quality control over anesthesia records, blood lists, blood transfusion records, gastro endoscopy inspection reports and bronchoscopy reports is strengthened, and the medical record defect rate checked in the part accounts for 2.5% of the medical record defect rates in 2012. Conclusion. Implementation of electronic medical records is conducive to monitoring and continuous improvement of the medical record quality of the hospital.