Evaluating the Content of the Electronic Patient Records

摘要

The delivery of good care and the ability to communicate effectively about patient care depends on the quality of the information available to all professions and between sectors. In addition the data in electronic patient records are used e.g. in clinical research, health system management, health services planning and government reporting. The quality of documentation of the electronic patient records is therefore of great importance. This paper presents the main points of a literature review focusing on evaluating the content of electronic patient records. The literature search was conducted in electronic databases Pubmed Medline and Cinalh. The literature indicates a lack of evaluating studies about the data elements and the structure of an electronic patient record. The documentation of patient care includes both narrative text and codes. The quality of the documentation is not always complete.