An experimental electronic patient record for stroke patients. Part 1: Situation analysis
In this article the paper record and its position in work practices is discussed, and is related to the situation at an inpatient clinic for which an electronic patient record (EPR) is in development. In addition reported research on innovations is discussed. An analysis of 42 clinical paper records gave insight into existing problems with paper records. The current work practices were analysed based on two periods of observations in the ward and eight in-depth interviews with questions about their daily work, communication in the ward and the role of the paper record in communication. The results indicate that several problems described in the literature were recognised only for a part of the medical and nursing records. One probable cause of insufficient communication between health care workers appeared to be the internal organisation of the paper records. The fact that the experimental EPR system will be small-scaled, introduces specific problems regarding communication with other departments that still work with paper records. Nevertheless, we conclude that also an electronic patient record designed for a specific setting has the potential to improve record keeping and communication between health care workers.
work nursing records health care medical records systems analysis