1. Medical
Documentation
Issues and Hurdles
Dr. Sameer Vankar
Senior Resident
Emergency Medicine
JPNATC,AIIMS,New Delhi

2. Medical Record Papers
• Disadvantages:
 Documentation issues
 Organizational issues-Storage & Retrieval
 Wear and Tear

3. Documentation issues

4. Storage

5. Wear & Tear

6. EMR
An electronic medical record (EMR) is a computerized
medical record created in an organization that delivers
care, such as a hospital

11. Patient’s entire health record
11
Cover Page Areas
Menu
Bar
View or add current problems
Lab reports
Hospital visit data

12. 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

13. Study Tool
Structured, closed ended questionnaire consisted of 12
questions based on:
Usability
Applicability
Security
Helpful in research of EMR

14. Question
Are you aware of CPRS (computerized patient record system)?
a) Yes
b) No
If your answer to the above question is ‘Yes’ please proceed below:
Usability:
1. Do you have problem in logging into CPRS?
a) Never
b) Sometimes
c) Very often
d) Always
2. Overall, how easy is the computerized MLC form?
a) Not at all
b) To some extent
c) easy
d) Very useful
3. Overall, how easy is the computerized transfer notes?
a) Not at all
b) To some extent
c) easy
d) Very easy
4. Overall, how easy is the computerized discharge summary?
a) Not at all
b) To some extent
c) easy
d) Very easy
5. Overall, how easy is the computerized entry of patient vitals?
a) Not at all
b) To some extent
c) easy
d) Very easy
Applicability:
6. Do you think this system is helpful in overall patient care?
a) Never
b) Sometimes
c) Very often
d) Always
7. Do you feel demographics are more accurately entered in all forms (MLC form,
transfer out forms, discharge summary) by using the computerized system?
a) Never
b) Sometimes
c) Very often
d) Always
8. Do you think computerized MLC form is helpful for police and judiciary (courts)?
a) Never
b) Sometimes
c) Very often
d) Always
Security:
10. Do you think data can be manipulated in system (after sign off)?
a) Never
b) Sometimes
c) Very often
d) Always
11. Do you think this system will help in improving transparency and accountability?
a) Never
b) Sometimes
c) Very often
d) Always
Research:
12. Do you feel this system can be helpful in research?
a) Never
b) Sometimes
c) Very often
d) Always

15. METHODOLOGY (CONTD.)
• Likert scale (LS) was used (Likert 1=worst, likert 4=best)
• Surveys were done on day- 20 ,
day- 45 day and
9 months of implementation of EMR
• Response of emergency care providers (ECP) were compiled
• Data analyzed by SPSS version 16

16. Result
4
3.5
3
2.5
2
1.5
1
0.5
0
2.23
2.5 2.45 2.41
2.71 2.72
3
2.82
1.41
2.77
3.32
S1 S2 S3

17. Hurdles

18. Hurdles

19. Hurdles

20. Hurdles

21. Advantages
• Relatively complete
• Tamper proof
• Learning
• Research
• Easy retrieval