The role of medical documentation in opinion health care employees

Abstract

Background. Medical documentation is an integral part of the services performed by medical personnel. Legal acts define very precisely the principles of keeping medical records and the scope of information that must be included in it. Objectives. Assessment of the role of medical documentation in the opinion of healthcare professionals. Material and methods. The study using the author’s questionnaire was carried out using the diagnostic survey method in the period from January to April 2019 in public and non-public healthcare facilities in Warsaw. The study included 246 people from medical staff: doctors, nurses and midwives, employed in public and private health care facilities. Results. In public health care facilities, medical documentation kept both in paper and electronic form in 85.3%. In non-public facilities, documentation in both versions is kept in 77.4%. In 70% employees of public health care facilities were trained how to maintain electronic medical records. 30% of respondents did not undergo such training. In the case of a private institution, the training was conducted among a smaller number of employees (62.3%). There was no training among 37.7% of employees. The vast majority of respondents in both public (85.9%) and non-public (84.9%) factories found that the unit in which they work has software enabling proper EDM support. 14.1% of employees from public and 15.1% from non-public healthcare facilities were of a different opinion. The most common form of access to electronic medical records was a login and password (doctors – 85.4%, midwives – 93.8%, nurses – 80.9%). None of the respondents chose the “no authorization” answer. An IT system failure is the most common problem among employees of public and private healthcare facilities using electronic medical records (63.9%). The remaining 36.1% of employees did not have this type of event. Over half of the respondents, i.e. 55.2% of respondents, believe that the introduction of EDM has facilitated work. 31.8% of all respondents said so definitely. According to 11.7%, the introduction of EDM is unlikely to improve work. The introduction of electronic medical records will definitely not improve the work of 1.3% of medical staff. The vast majority of medical personnel, i.e. 85.6%, consider the introduction of electronic documentation to be safer than paper documentation. Rather, 11.7% of the staff do not think and 2.7% do not think so. Conclusions. It was found that public and private health care facilities are prepared to introduce Electronic Medical Documentation. There is a need to increase the number of training sessions on the use of Electronic Medical Records and issues related to medical law among medical personnel in public and non-public healthcare facilities. The main disadvantages of Electronic Medical Records that hinder work according to medical staff are: the need for continuous internet connection, system errors that prolong the time it takes to complete the documentation. The relationship between age and difficulty of using the Electronic Medical Documentation system was found. He main disadvantages of Electronic Medical Records that hinder work according to medical staff are: the need for continuous internet connection, system errors that prolong the time it takes to complete the documentation. The relationship between age and difficulty of using the Electronic Medical Documentation system was found.