The effects of an electronic medical record on the completeness of documentation in the anesthesia record

•The completeness of documentation of electronic anesthesia record was improved.•There was no improvement of the completeness of documentation in manually recorded items of electronic anesthesia record.•The major reason that improved the completeness of electronic anesthesia record was reuse of same items from EMR.

ObjectivesThe purpose of this study is to evaluate the completeness of anesthesia recording before and after the introduction of an electronic anesthesia record.MethodsThe study was conducted in a Korean teaching hospital where the EMR was implemented in October 2008. One hundred paper anesthesia records from July to September 2008 and 150 electronic anesthesia records during the same period in 2009 were randomly sampled. Thirty-four essential items were selected out of all the anesthesia items and grouped into automatically transferred items and manual entry items. 1, .5 and 0 points were given for each item of complete entry, incomplete entry and no entry respectively. The completeness of documentation was defined as the sum of the scores. The influencing factors on the completeness of documentation were evaluated in total and by the groups.ResultsThe average completeness score of the electronic anesthesia records was 3.15% higher than that of the paper records. A multiple regression model showed the type of the anesthesia record was a significant factor on the completeness of anesthesia records in all items (β = .98, p < .05) and automatically transferred items (β = .56, p < .01). The type of the anesthesia records had no influence on the completeness in manual entry items.ConclusionsThe completeness of an anesthesia record was improved after the implementation of the electronic anesthesia record. The reuse of the data from the EMR was the main contributor to the improved completeness.