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The evolution of the medical record from paper to digital: an ENT perspective

Published online by Cambridge University Press:  12 September 2022

C Murphy Open the ORCID record for C Murphy [Opens in a new window]  and
I J Keogh
C Murphy*
Affiliation:
Department of Otolaryngology, University College Hospital Galway, School of Medicine, National University of Ireland Galway, Galway, Ireland
I J Keogh
Affiliation:
Department of Otolaryngology, University College Hospital Galway, School of Medicine, National University of Ireland Galway, Galway, Ireland
*
Author for correspondence: Dr Claudine Murphy, Department of Otolaryngology, University College Hospital Galway, Galway, Ireland E-mail: claudinemurphy583@gmail.com
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Abstract

Objectives

A national electronic health record is being procured for Health Service Executive hospitals in Ireland. A number of hospitals have implemented an electronic document management system. This study aimed to investigate the efficiency and safety of the electronic document management system in our centre.

Methods

A retrospective audit was performed of patients operated on at Galway University Hospital. The availability and location of patients’ admission data on the electronic document management system were recorded. These data were analysed using Microsoft Excel software, version 16.45.

Results

The records of 100 patients were analysed. The main findings were: 5 per cent of operation notes were missing, 80 per cent were in the incorrect section, while 15 per cent were in the correct ‘procedure’ section on the electronic document management system.

Conclusion

This study shows there is potential for error with ‘paper-light’ solutions, whereby delayed scanning, misfiling of scanned records and missing records may lead to significant delays in treatment and potential patient safety issues.

Keywords

Management AuditCommunicationHealth Services ResearchInformaticsInternet
Type
Main Article
Information
The Journal of Laryngology & Otology , Volume 137 , Issue 3 , March 2023 , pp. 246 - 248
Copyright
Copyright © The Author(s), 2022. Published by Cambridge University Press on behalf of J.L.O. (1984) LIMITED

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Footnotes

Dr C Murphy takes responsibility for the integrity of the content of the paper

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