Can temporary paper-based patient records sensibly complete an electronic patient record?
OBJECTIVE
In the department of internal medicine of Heidelberg University Hospital (HUH), medical patient records are archived electronically. Since there are still paper-based external documents, a temporary patient record is maintained for these documents during the patient's stay. Afterwards, the paper-based documents are scanned, indexed and integrated in the electronic patient record (EPR). To ensure process quality we evaluated quality and availability of scanned documents in the EPR.


METHODS
Observation study, structured interviews, systematic quantitative before-after comparison.


RESULTS
The workflow takes place according to the guidelines of HUH. Nevertheless, there are variations in the different wards which may influence the quality. Of 343 scanned documents about 90% showed no loss of information. Most of the documents with loss of information were ECG-curves. Four documents (1.2%) could not be found in the EPR. All documents were assigned to the correct patient and episode of care. The mean time from patient discharge to availability of scanned documents in the EPR system was 36 days.


CONCLUSIONS
Due to external paper-based documents, a complete EPR is currently not possible. A temporary paper-based patient record in addition to the EPR is not an optimum procedure but feasible. The quality of the scanned, indexed and integrated documents in the EPR is high and the availability is sufficient.
Knaup
Petra
P
University of Heidelberg, Department of Medical Informatics, Heidelberg, Germany. petra.knaup@med.uni-heidelberg.de
Pilz
Jochen
J
Thalheimer
Markus
M
D004282:Documentation; D017598:Efficiency, Organizational; D005858:Germany; D008500:Medical Records Department, Hospital / Q000458:organization & administration; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*