title: [Information technology and medical record routines in hospitals in the health care region 2].
abstract: Structure, standard and efficient methods in paper medical records are important for a successful implementation of computerised medical records. We have conducted a survey among 26 somatic hospitals in a Norwegian region regarding present routines and use of information technology in patients records. The hospitals use six different patient administration systems, six laboratory, six radiology, and approximately 20 different specialist systems. 16 hospitals use three different electronic journal/documentation systems. Ten hospitals use the Word word processor for patient records. The full potential of word processing is not utilised. Digital dictation is seldom used; few hospitals have 24-hours service for documentation, and information technology is not used for documentation in nursing care. Four hospitals use microfilm. The survey shows that improvement is needed in order to achieve coordinated and effective use of information technology and manual routines in hospital medical records.
authors.affiliation: Administrasjonen Baerum sykehus, Baerum Postterminal.
authors.forename: G M
authors.initials: GM
authors.lastname: Jacobsen
authors.forename: N
authors.initials: N
authors.lastname: Stangeland
authors.forename: T L
authors.initials: TL
authors.lastname: Velund
authors.forename: O
authors.initials: O
authors.lastname: Blørstad
mesh_terms: D006747:Hospital Communication Systems; D016490:Integrated Advanced Information Management Systems; D008498:Medical Record Linkage; D016347:Medical Records Systems, Computerized; D009664:Norway; D009737:Nursing Records; D012984:Software; D011795:Surveys and Questionnaires
vernacular_title: Informasjonsteknologi og journalrutiner ved sykehus i helseregion 2.