Medical record abstraction in a hospital with paper-based records: experience of early career psychiatrists in northern Borneo

Farah Ahmad Shahabuddin and Kheng, Yee Wah and Ryna Imma Buji and Nurul Syeema Zulkafli and Shea, Wah Lee and Hui, Lee Soon and Siau, Yun Yap and Vuii, Law and Loo, Jiann Lin (2020) Medical record abstraction in a hospital with paper-based records: experience of early career psychiatrists in northern Borneo. BJPsych International, 17. pp. 43-44. ISSN 2056-4740 (P-ISSN) , 2058-6264 (E-ISSN)

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Abstract

We used medical record abstraction to conduct research in a psychiatric hospital with paper-based medical records. The challenges we encountered included: the difficulty in retrieving files; the extensive effort and time needed to extract clinical information; the lack of a standardised documentation system of medical records; and the need for advanced computer literacy. To promote future research using electronic medical records, potential solutions include creating a registry of all patients receiving treatment, as well as equipping busy clinicians with computer skills.

Item Type:	Article
Keyword:	Medical record abstraction , MRA , Clinical research , Paper-based medical record , Documentation
Subjects:	R Medicine > RC Internal medicine > RC31-1245 Internal medicine > RC321-571 Neurosciences. Biological psychiatry. Neuropsychiatry > RC346-429 Neurology. Diseases of the nervous system Including speech disorders > RC435-571 Psychiatry
Department:	FACULTY > Faculty of Medicine and Health Sciences
Depositing User:	SAFRUDIN BIN DARUN -
Date Deposited:	03 May 2022 22:44
Last Modified:	03 May 2022 22:44
URI:	https://eprints.ums.edu.my/id/eprint/32506

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