ArticleJMIR medical informatics2024
The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis.
Article in JMIR medical informatics, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers, 3 of them syntheses that pooled it.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
9 citing papers in PubMed, 3 syntheses or guidelines pooled it.
- Towards Electronic Medical Record (EMR) utilization in developing countries: a conceptual model based on systematic literature review.BMC medical informatics and decision making · 2026Pooled it
- Application of artificial intelligence tools and clinical documentation burden: a systematic review and meta-analysis.BMC medical informatics and decision making · 2025Pooled it
- Data quality assessment in healthcare, dimensions, methods and tools: a systematic review.BMC medical informatics and decision making · 2025Pooled it
- Why is the data quality of hospital morbidity so heterogeneous? A nationwide survey of Portuguese clinical coders.Archives of public health = Archives belges de sante publique · 2026Article
- Digital health literacy as a predictor of patient safety culture: evidence from a multi-centre study of Jordanian nurses.Journal of pharmaceutical policy and practice · 2026Article
- Article
- Enhancing Clinical History Taking Through the Implementation of a Streamlined Electronic Questionnaire System at a Pediatric Headache Clinic: Development and Evaluation Study.JMIR medical informatics · 2024Article
- Differences in changes of data completeness after the implementation of an electronic medical record in three surgical departments of a German hospital-a longitudinal comparative document analysis.BMC medical informatics and decision making · 2024Article
- Roger's diffusion of innovations theory and the adoption of a patient portal's digital anamnesis collection tool: study protocol for the MAiBest project.Implementation science communications · 2024Article
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Authors and funding
11 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundElectronic medical records (EMR) are considered a key component of the health care system's digital transformation. The implementation of an EMR promises various improvements, for example, in the availability of information, coordination of care, or patient safety, and is required for big data analytics. To ensure those possibilities, the included documentation must be of high quality. In this matter, the most frequently described dimension of data quality is the completeness of documentation. In this regard, little is known about how and why the completeness of documentation might change after the implementation of an EMR.
objectiveThis study aims to compare the completeness of documentation in paper-based medical records and EMRs and to discuss the possible impact of an EMR on the completeness of documentation.
methodsA retrospective document analysis was conducted, comparing the completeness of paper-based medical records and EMRs. Data were collected before and after the implementation of an EMR on an orthopaedical ward in a German academic teaching hospital. The anonymized records represent all treated patients for a 3-week period each. Unpaired, 2-tailed t tests, chi-square tests, and relative risks were calculated to analyze and compare the mean completeness of the 2 record types in general and of 10 specific items in detail (blood pressure, body temperature, diagnosis, diet, excretions, height, pain, pulse, reanimation status, and weight). For this purpose, each of the 10 items received a dichotomous score of 1 if it was documented on the first day of patient care on the ward; otherwise, it was scored as 0.
resultsThe analysis consisted of 180 medical records. The average completeness was 6.25 (SD 2.15) out of 10 in the paper-based medical record, significantly rising to an average of 7.13 (SD 2.01) in the EMR (t
conclusionsImplementing EMRs can influence the completeness of documentation, with a possible change in both increased and decreased completeness. However, the mechanisms that determine those changes are often neglected. There are mechanisms that might facilitate an improved completeness of documentation and could decrease or increase the staff's burden caused by documentation tasks. Research is needed to take advantage of these mechanisms and use them for mutual profit in the interests of all stakeholders.
trial registrationGerman Clinical Trials Register DRKS00023343; https://drks.de/search/de/trial/DRKS00023343.
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