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

Objective A national Electronic Health Record (EHR) is being procured for Health Service Executive hospitals in Ireland. A number of hospitals have implemented Electronic Document Management Systems (EDMS).The aim of this study was to look at the efficiency and safety of the EDMS in our centre. Methods A retrospective audit was performed of patients operated on at Galway University Hospital. The location of and availability of patients admission data on the EDMS was recorded. These data were analysed using Microsoft Excel 16.45. Results 100 records of patients were analysed. The main findings were: 5% of operation notes were missing, 80% of were in the incorrect section while 15% were in the correct “procedure” section on the EDMS. Conclusion This study shows there is potential for error with “paper-light” solutions where delayed scanning, misfiling of scanned records, and missing records may lead to significant delays in treatment and potential patient safety issues.