文章基本信息

标题：Indicators of missing Electronic Medical Record (EMR) discharge summaries: A retrospective study on data from a large Canadian cohort
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作者：Natalie Wiebe ; Yuan Xu ; Abdel Aziz Shaheen 等
期刊名称：International Journal of Population Data Science
电子版ISSN：2399-4908
出版年度：2020
卷号：5
期号：1
页码：1-10
DOI：10.23889/ijpds.v5i3.1352
出版社：Swansea University
摘要：Introduction and Objectives: Electronic medical records (EMRs), specifically the discharge summary (DS), can improve secondary use data availability and interprofessional communication. We aimed to assess the completeness of our EMRs by assessing the presence of a DS in the EMR. Additionally, we assessed for indicators of a missing DS. Methods: A chart review was conducted on 3,011 inpatient charts in Calgary, Alberta. 893 charts were missing an electronic DS. A 10% sample was drawn to assess for presence of a paper DS. A Chi-square test, Fisher’s test and logistic regression assessed for associations between electronic DS absence and i) patient and hospital characteristics, and ii) patient comorbidities Results: The univariate analyses showed that age, being a surgical patient, a Charlson Comorbidity Index (CCI) of
关键词：electronic medical record; discharge summary; missing documentation; inpatient