Dr.Prakash R. Mishra Assistant Professor Department of Emergency Medicine AIIMS, N.Delhi.

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