Comparison of patient data in parallel records: The sign-out sheet and the electronic medical record

摘要

Electronic medical record and separate sign-out system data (code status, location, medications and laboratory results) from 60 patients were compared to assess the impact of parallel data systems. In addition, a survey was administered to 74 Internal Medicine residents to characterize what elements they self-report using in their sign-out system. The survey results indicated that residents use the separate sign-out system to support hand-off of care, but also patient care. The data comparison showed that while code status data matched for all patients, 28.3% of patients had a location entered into the sign-out system that did not match the medical record. 46 (76.7%) patients had a medication reported in the sign-out report that did not match the medical record. Of 180 laboratory values compared, 130 (72%) matched the most recent value or a value within the past 24 hours. Using a criterion of “medically relevant matches”, a test of proportion indicated that significantly more laboratory values agree, thus supporting the hypothesis that physicians are less likely to update data when changes are not medically relevant. To reduce workload and the amount of inaccurate information being passed to physicians, sign-out functionality should be integrated into electronic medical record systems.