Practice Status of Electronic Medical Records and Improvement Measures in EMRs

Objective. The goal of this study is to research and analyze problems in some hospitalized electronic medical records after a comprehensive EMR system was implemented at Peking Hospital during a recent one-year period. Methods. A total of 3000 hospitalization electronic medical records of our hospital, from July, 2011 to June, 2012, are randomly selected. Three inspectors check the data quality of the selected electronic medical records, and fill the questionnaires and analyze the problems in them. The existing problems are classified according to the following six types: (1) copy and paste of electronic records (2) excessive use of electronic templates (3) lack of patient or physician signatures (4) inaccurate recording time (5) untimely recording (6) others. The electronic medical records are divided into four groups based on reasons for defects: physicians, nurses, patients or relatives, and general staff such as general information recorders and medical record coders. Results. In the six types of main problems, the defect rates of the selected electronic medical records are 16.5%, 27.8%, 9.2%, 3.9%, 2.7% and 5.5%, respectively. The defect rates in different groups are obviously different. The use permissions of electronic medical records have a certain impact on the defect rates. Conclusions. In the process of generating electronic medical records, each group should be responsible and dutiful according to work requirements, and the electronic medical record system can be designed for the use of management authority, modification by management authority, and a professional template for professionals to facilitate use and reduce errors. Establishing the electronic medical record system should include a perfect system management application program, senior physician check and approval and signature of EMR, training about law and regulations of electronic medical record writing, establishment of electronic medical record reviewing flow, constant system improvement and network construction of electronic medical record.