Abstract
We are currently using a “Card-type” electronic patient record (EPR) system, which has been created by adding a customized interface layer between FileMaker Pro and the vendor-made EPR system. To investigate the ideal description method for EPRs, we analyzed the nighttime outpatient records and evaluated the quality of description and that of medical performance. In our hospital, the 1st and 2nd grade residents take charge of the nighttime outpatients. From April 2006 to March 2007, “Roll paper style” EPR was used. After April 2007, “Card-type” EPR was equipped for nighttime outpatients. We analyzed the data in EPRs for nighttime outpatients to determine whether proper descriptions were being provided in the important fields. We also evaluated the accuracy of diagnosis and treatments. The assessments showed that the number of the character to describe patient's record by “Card-type” EPR were twice compared with “Roll paper style” EPR, and the important aspects were well described in “Card-type” EPR. “Good performance” was achieved in “Card-type” EPR. Using our EPRs, many important aspects could be described, and the diagnosis and treatment was shown to be satisfactory. The prepared input fields may improve the medical performance.
