Abstract
AbstractObjective. The goal of this study is to research and analyze problems in some hospitalized electronic medical records after a comprehensive EMR system was implemented at Peking Hospital during a recent one-year period. Methods. A total of 3000 hospitalization electronic medical records of our hospital, from July, 2011 to June, 2012, are randomly selected. Three inspectors check the data quality of the selected electronic medical records, and fill the questionnaires and analyze the problems in them. The existing problems are classified according to the following six types: (1) copy and paste of electronic records (2) excessive use of electronic templates (3) lack of patient or physician signatures (4) inaccurate recording time (5) untimely recording (6) others. The electronic medical records are divided into four groups based on reasons for defects: physicians, nurses, patients or relatives, and general staff such as general information recorders and medical record coders. Results. In the six types...
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