Comparison of handheld computer-assisted and conventional paper chart documentation of medical records. A randomized, controlled trial.
BACKGROUND
Daily documentation and maintenance of medical record quality is a crucial issue in orthopaedic surgery. The purpose of the present study was to determine whether the introduction of a handheld computer could improve both the quantitative and qualitative aspects of medical records.


METHODS
A series of consecutive patients who were admitted for the first time to a thirty-six-bed orthopaedic ward of an academic teaching hospital for a planned operation or any other treatment of an acute injury or chronic condition were randomized to daily documentation of their clinical charts on a handheld computer or on conventional paper forms. The electronic documentation consisted of a specially designed software package on a handheld computer for bedside use with structured decision trees for examination, obtaining a history, and coding. In the control arm, chart notes were compiled on standard paper forms and were subsequently entered into the hospital's information system. The number of documented ICD (International Classification of Diseases) diagnoses was the primary end point for sample size calculations. All patient charts were reread by an expert panel consisting of two surgeons and the surgical quality assurance manager. These experts assigned quality ratings to the different documentation systems by scrutinizing the extent and accuracy of the patient histories and the physical findings as assessed by daily chart notes.


RESULTS
Eighty patients were randomized to one of the two documentation arms, and seventy-eight (forty-seven men and thirty-one women) of them were eligible for final analysis. Documentation with the handheld computer increased the median number of diagnoses per patients from four to nine (p < 0.0001), but it produced some overcoding for false or redundant items. Documentation quality ratings improved significantly with the introduction of the handheld device (p < 0.01) with respect to the correct assessment of a patient's progress and translation into ICD diagnoses. Various learning curve effects were observed with different operators. Study physicians assigned slightly better practicability ratings to the handheld device.


CONCLUSIONS
The preliminary data from this study suggest that handheld computers may improve the quality of hospital charts in orthopaedic surgery.


METHODS
Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.
Stengel
Dirk
D
Clinical Epidemiology Division, Department of Orthopedic and Trauma Surgery, Ernst-Moritz-Arndt-University, Friedrich Loeffler Strasse 23b, 17489 Greifswald, Germany. dirk.stengel@ukb.de
Bauwens
Kai
K
Walter
Martin
M
Köpfer
Thilo
T
Ekkernkamp
Axel
A
D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D034201:Computers, Handheld / Q000592:standards*; D004282:Documentation / Q000379:methods*; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D038801:International Classification of Diseases / Q000706:statistics & numerical data; D008297:Male; D008499:Medical Records / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D008505:Medical Staff, Hospital / Q000193:education / Q000523:psychology; D008875:Middle Aged; D019637:Orthopedic Procedures; D010209:Paper / Q000592:standards*; D019095:Point-of-Care Systems / Q000592:standards; D036301:Qualitative Research; D011785:Quality Assurance, Health Care; D012044:Regression Analysis