The evolution of the medical record from paper to digital: an ENT perspective

Objectives A national electronic health record is being procured for Health Service Executive hospitals in Ireland. A number of hospitals have implemented an electronic document management system. This study aimed to investigate the efficiency and safety of the electronic document management system in our centre. Methods A retrospective audit was performed of patients operated on at Galway University Hospital. The availability and location of patients' admission data on the electronic document management system were recorded. These data were analysed using Microsoft Excel software, version 16.45. Results The records of 100 patients were analysed. The main findings were: 5 per cent of operation notes were missing, 80 per cent were in the incorrect section, while 15 per cent were in the correct 'procedure' section on the electronic document management system. Conclusion This study shows there is potential for error with 'paper-light' solutions, whereby delayed scanning, misfiling of scanned records and missing records may lead to significant delays in treatment and potential patient safety issues.