Medical Documentation in Emergency Department: Issues and Hurdles

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  Dr.Prakash R. Mishra Assistant Professor Department of Emergency Medicine AIIMS, N.Delhi.
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  • 1. Medical Documentation in Emergency Department: Issues and Hurdles Dr.Prakash R. Mishra Assistant Professor Department of Emergency Medicine AIIMS, N.Delhi.
  • 2. Not documented--------Not Done
  • 3. Non documentation • Time pressure • High patient inflow • Administrative job • Lack of interest • Ignorance
  • 4. Relevance • Personal information • History • Clinical findings • Radiological and lab.findings • Treatment provided • Course in hospital • Outcome
  • 5. Advantages • Chronological documentation of patient care • Communication • Co-ordination of follow up care • Discharge instruction communication • Legal protection • Reimbursement • Data mining for research activities
  • 6. INTERPRETATION ?
  • 7. Gaps • Handwriting issues • Non-Reproducibility • Signature • Address, designation and registration number of Doctor • Not tamper proof • Storage issue
  • 8. Storage
  • 9. e-MRS
  • 10. Pearls • Hand writing not a problem • Template based, uniformity • Tamper-proof • Electronic signature • Identity of issuing doctor • Space management
  • 11. Resistance to change
  • 12. Personal Fear Socio- cultural factors Values and ideas Trust Perception Cost Causes
  • 13. To Assess the Perception of Emergency Care Providers Towards the Implementation of Electronic Medical Record System in Emergency Department of a Level - 1 Trauma Centre
  • 14. METHODOLOGY • Study design- Qualitative survey • Performance centre - ED of JPN Apex Trauma Centre, AIIMS • Study duration-February to October 2010 (3 surveys) • Study Group - 22 Emergency Care Providers Doctors 8 Nurses 14 Total 22
  • 15. Study Tool Structured, closed ended questionnaire consisted of 12 questions based on : Usability Applicability Security Helpful in research
  • 16. METHODOLOGY (CONTD.) • Likert scale (LS) was used (Likert 1 = worst, Likert 4 = best) • Surveys were done on day- 20, day- 45 and 9 months of implementation of EMR • Response of emergency care providers (ECP) were compiled • Data analyzed by SPSS version 16
  • 17. • The data on perception of security concerns were comparable among survey1, survey2 and survey3:[S1:LS:2.25],[S2:LS:2.09], [S3:LS:2.41] • Initial satisfaction was strongly associated with perception of usefulness of data mining for research purpose Result (contd.)
  • 18. Overcoming resistance • Communication • Education and encouragement • Accepting mistakes • Audits and training • Highlighting the benefits • Facilitation and support • Reward
  • 19. Thank You
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