title: The effects of an electronic medical record on the completeness of documentation in the anesthesia record.
abstract: OBJECTIVE
  The purpose of this study is to evaluate the completeness of anesthesia recording before and after the introduction of an electronic anesthesia record.
  
  
  METHODS
  The study was conducted in a Korean teaching hospital where the EMR was implemented in October 2008. One hundred paper anesthesia records from July to September 2008 and 150 electronic anesthesia records during the same period in 2009 were randomly sampled. Thirty-four essential items were selected out of all the anesthesia items and grouped into automatically transferred items and manual entry items. 1, .5 and 0 points were given for each item of complete entry, incomplete entry and no entry respectively. The completeness of documentation was defined as the sum of the scores. The influencing factors on the completeness of documentation were evaluated in total and by the groups.
  
  
  RESULTS
  The average completeness score of the electronic anesthesia records was 3.15% higher than that of the paper records. A multiple regression model showed the type of the anesthesia record was a significant factor on the completeness of anesthesia records in all items (β=.98, p<.05) and automatically transferred items (β=.56, p<.01). The type of the anesthesia records had no influence on the completeness in manual entry items.
  
  
  CONCLUSIONS
  The completeness of an anesthesia record was improved after the implementation of the electronic anesthesia record. The reuse of the data from the EMR was the main contributor to the improved completeness.
authors.affiliation: Graduate School of Public Health, Younsei University, 250 Seongsnanno, Seodaemun-Gu, Seoul, Republic of Korea.
authors.forename: Junghwa
authors.initials: J
authors.lastname: Jang
authors.forename: Seung Hum
authors.initials: SH
authors.lastname: Yu
authors.forename: Chun-Bae
authors.initials: CB
authors.lastname: Kim
authors.forename: Youngkyu
authors.initials: Y
authors.lastname: Moon
authors.forename: Sukil
authors.initials: S
authors.lastname: Kim
mesh_terms: D000758:Anesthesia / Q000592:standards*; D000761:Anesthesia Department, Hospital / Q000592:standards*; D004282:Documentation / Q000592:standards*; D006751:Hospital Information Systems / Q000592:standards*; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*
keywords: Completeness of documentation; Electronic anesthesia record; Electronic medical record