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- Title
Medical record abstraction in a hospital with paper-based records: experience of early career psychiatrists in northern Borneo.
- Authors
Ahmad Shahabuddin, Farah; Wah, Kheng Yee; Buji, Ryna Imma; Zulkafli, Nurul Syeema; Lee, Shea Wah; Soon, Hui Lee; Yap, Siau Yun; Law, Vuii; Loo, Jiann Lin
- 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.
- Subjects
BORNEO; MEDICAL records; HOSPITAL records; ELECTRONIC health records; COMPUTER literacy; PSYCHIATRISTS
- Publication
BJPsych International, 2020, Vol 17, Issue 2, p43
- ISSN
2056-4740
- Publication type
Article
- DOI
10.1192/bji.2019.29