The Effectiveness of Automated Nursing Note Recording System: Patient Moving Information and Diagnostic Test Information in Emergency Room / 대한의료정보학회지

ABSTRACT

OBJECTIVE: The main complaints of users in existing electronic medical record systems are the complexity of recording system and long recording time. The records of patient moving and the diagnostic test performed outside emergency room are important. But emergency nurses can't record such information exactly and completely because of the highest priorities of emergency treatment and its record in overcrowded emergency room. METHODS: Emergency electronic medical record team of Asan Medical Center developed the automatic recording system of patient moving and diagnostic test information in 2006. The effectiveness of this system was evaluated by comparing the number of records in manual and automatic documentations before and after the system application. RESULTS: The numbers of total records per patient-order were not changed statistically, but the number of manual patient moving and diagnostic test records significantly reduced from 0.50+/-0.69 to 0.31+/-0.47 (p < 0.01). The number of automatic patient moving and diagnostic test records per patient-order was 1.98+/-0.99. CONCLUSION: This automatic recording system can reduce indirect nursing time and give more exact and complete information to emergency medical personnel. The effort to simplify documentation in electronic medical record systems is important, but 'automatic recording' strategy is also needed.