Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients
Chris Witkowski A , Lara Kimmel B C , Elton Edwards A C and Filip Cosic
A D
A Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Vic., Australia. Email: cjwit1@gmail.com; ere@bigpond.net.au
B Department of Physiotherapy, Alfred Hospital, Melbourne, Vic., Australia. Email: l.kimmel@alfred.org.au
C Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic., Australia.
D Corresponding author. Email: filcosic@gmail.com
Australian Health Review 46(2) 204-209 https://doi.org/10.1071/AH21112
Submitted: 31 March 2021 Accepted: 15 August 2021 Published: 9 November 2021
Abstract
Objective The medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR).
Methods A review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery.
Results In all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P = 0.032).
Conclusion The EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record.
What is known about the topic? Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record.
What does this paper add? Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement.
What are the implications for practitioners? The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.
Keywords: access and evaluation, documentation, fractures, health care quality, medical records, orthopaedics.
References
[1] Thomas J. Medical records and issues in negligence. Indian J Urol 2009; 25 384–8.| Medical records and issues in negligence.Crossref | GoogleScholarGoogle Scholar | 19881136PubMed |
[2] Feather H, Morgan N. Risk management: role of the medical record department. Top Health Rec Manage 1991; 12 40–8.
| 10114765PubMed |
[3] Fernando KJ, Siriwardena AK. Standards of documentation of the surgeon-patient consultation in current surgical practice. Br J Surg 2001; 88 309–12.
| Standards of documentation of the surgeon-patient consultation in current surgical practice.Crossref | GoogleScholarGoogle Scholar | 11167887PubMed |
[4] Al-Mahrouqi H, Oumer R, Tapper R, Roberts R. Post-acute surgical ward round proforma improves documentation. BMJ Qual Improv Rep 2013; 2 u201042.w688
| Post-acute surgical ward round proforma improves documentation.Crossref | GoogleScholarGoogle Scholar | 26734192PubMed |
[5] Patel AG, Mould T, Webb PJ. Inadequacies of hospital medical records. Ann R Coll Surg Engl 1993; 75 7–9.
| 8422161PubMed |
[6] Tan EW, Ting BL, Jia X, Skolasky RL, McFarland EG. Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients. Am J Med Qual 2013; 28 60–8.
| Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.Crossref | GoogleScholarGoogle Scholar | 22798636PubMed |
[7] Cascio BM, Wilckens JH, Ain MC, Toulson C, Frassica FJ. Documentation of acute compartment syndrome at an academic health-care center. J Bone Joint Surg Am 2005; 87 346–50.
| Documentation of acute compartment syndrome at an academic health-care center.Crossref | GoogleScholarGoogle Scholar | 15687158PubMed |
[8] Cosic F, Kimmel L, Edwards E. Medical record keeping and system performance in orthopaedic trauma patients. Aust Health Rev 2016; 40 619–24.
| Medical record keeping and system performance in orthopaedic trauma patients.Crossref | GoogleScholarGoogle Scholar | 26885685PubMed |
[9] Shayah A, Agada FO, Gunasekaran S, Jassar P, England RJA. The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard. Int J Clin Pract 2007; 61 677–9.
| The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard.Crossref | GoogleScholarGoogle Scholar | 17394439PubMed |
[10] Singh R, Chauhan R, Anwar S. Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study. J Eval Clin Pract 2012; 18 578–80.
| Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study.Crossref | GoogleScholarGoogle Scholar | 21210903PubMed |
[11] Rogers BA, Pleat J. Is there adequate information on operation notes? The application of the Royal College of Surgeons of England guidelines. J Perioper Pract 2010; 20 339–42.
| Is there adequate information on operation notes? The application of the Royal College of Surgeons of England guidelines.Crossref | GoogleScholarGoogle Scholar | 20954514PubMed |
[12] Bateman ND, Carney AS, Gibbin KP. An audit of the quality of operation notes in an otolaryngology unit. J R Coll Surg Edinb 1999; 44 94–5.
| 10230203PubMed |
[13] Din R, Jena D, Muddu BN, Jennna D. The use of an aide-memoire to improve the quality of operation notes in an orthopaedic unit. Ann R Coll Surg Engl 2001; 83 319–20.
| 11806555PubMed |
[14] Baigrie RJ, Dowling BL, Birch D, Dehn TC. An audit of the quality of operation notes in two district general hospitals. Are we following Royal College guidelines? Ann R Coll Surg Engl 1994; 76 8–10.
| 8017801PubMed |
[15] Bolton P, Mira M, Kennedy P, Lahra MM. The quality of communication between hospitals and general practitioners: an assessment. J Qual Clin Pract 1998; 18 241–7.
| The quality of communication between hospitals and general practitioners: an assessment.Crossref | GoogleScholarGoogle Scholar | 9862661PubMed |
[16] Callen JL, Alderton M, McIntosh J. Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries. Int J Med Inform 2008; 77 613–20.
| Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries.Crossref | GoogleScholarGoogle Scholar | 18294904PubMed |
[17] Maslove DM, Leiter RE, Griesman J, Arnott C, Mourad O, Chow C-M, et al Electronic versus dictated hospital discharge summaries: a randomized controlled trial. J Gen Intern Med 2009; 24 995–1001.
| Electronic versus dictated hospital discharge summaries: a randomized controlled trial.Crossref | GoogleScholarGoogle Scholar | 19609623PubMed |
[18] Soto CM, Kleinman KP, Simon SR. Quality and correlates of medical record documentation in the ambulatory care setting. BMC Health Serv Res 2002; 2 22
| Quality and correlates of medical record documentation in the ambulatory care setting.Crossref | GoogleScholarGoogle Scholar | 12473161PubMed |
[19] Edwards ST, Neri PM, Volk LA, Schiff GD, Bates DW. Association of note quality and quality of care: a cross-sectional study. BMJ Qual Saf 2014; 23 406–13.
| Association of note quality and quality of care: a cross-sectional study.Crossref | GoogleScholarGoogle Scholar | 24287259PubMed |
[20] Burke HB, Sessums LL, Hoang A, Becher DA, Fontelo P, Liu F, et al Electronic health records improve clinical note quality. J Am Med Inform Assoc 2015; 22 199–205.
| Electronic health records improve clinical note quality.Crossref | GoogleScholarGoogle Scholar | 25342178PubMed |
[21] Cascio BM, Pateder DB, Farber AJ, Kramer DE, Ain MC, Frassica FJ. Improvement in documentation of compartment syndrome with a chart insert. Orthopedics 2008; 31 364
| Improvement in documentation of compartment syndrome with a chart insert.Crossref | GoogleScholarGoogle Scholar | 19292285PubMed |
[22] Humphreys T, Shofer FS, Jacobson S, Coutifaris C, Stemhagen A. Preformatted charts improve documentation in the emergency department. Ann Emerg Med 1992; 21 534–40.
| Preformatted charts improve documentation in the emergency department.Crossref | GoogleScholarGoogle Scholar | 1570909PubMed |
[23] Umar JE, Ahmad N, Healy J, Kadoglou N. A surgical clerking proforma: Impact on quality and completeness of documentation for surgical admissions. Int J Surg 2013; 11 649
| A surgical clerking proforma: Impact on quality and completeness of documentation for surgical admissions.Crossref | GoogleScholarGoogle Scholar |
[24] Wallace SA, Gullan RW, Byrne PO, Bennett J, Perez-Avila CA. Use of a pro forma for head injuries in the accident and emergency department–the way forward. J Accid Emerg Med 1994; 11 33–42.
| Use of a pro forma for head injuries in the accident and emergency department–the way forward.Crossref | GoogleScholarGoogle Scholar | 7921548PubMed |
[25] McGain F, Cretikos MA, Jones D, Van Dyk S, Buist MD, Opdam H, et al Documentation of clinical review and vital signs after major surgery. Med J Aust 2008; 189 380–3.
| Documentation of clinical review and vital signs after major surgery.Crossref | GoogleScholarGoogle Scholar | 18837681PubMed |
