Reliability of Paper-Based Routine Documentation in Psychiatric Inpatient Care and Recommendations for Further Improvement

Abstract

Background: Health services research is of increasing importance in current psychiatry. Therefore, large datasets and aggregation of data generated by electronic routine documentation due to legal, financial, or administrative purposes play an important role. However, paper-based routine documentation is still of interest. It remains relevant in less developed health care systems, in emergency settings, and in long-term retrospective and historical studies. Whereas studies examining the reliability of electronic routine documentation support the application of routine data for research purposes, our knowledge regarding reliability of paper-based routine documentation is still very sparse.Methods: Basic documentation (BADO) was completed on paper forms and digitalized manually for all inpatients of the

Evaluating Antibiotic Treatment Guideline Adherence to Ongoing Antibiotic Stewardship in a Tertiary Care Setting: A Retrospective Observational Study

“…The validated paper-based clinical record form (CRF) [ 21 ] with admissible 28 items having acceptable item objective congruence indices was used to extract the specific patient data, which were based on WHO indicators [ 22 ], from the electronic medical records at the Medical Record Department with permission from the hospital and the responsible medical directors. Patient data on unique hospital numbers archived by using the ICD-10 code, cases with pneumonia, UTI, and SSTI (Supplementary Table 1 ) included demographic data, clinical diagnosis, antibiotic prescription data, antibiotic class, route of administration, duration of therapy, and antimicrobial sensitivity test results.…”

Standardized Comparison of Voice-Based Information and Documentation Systems to Established Systems in Intensive Care: Crossover Study

“…Paper documentation has the advantage of being cost-efficient and simple to use, as no IT infrastructure has to be implemented [ 23 ]. However, disadvantages include the lack of on-site documentation, the lack of simultaneous access, and redundancy and ineffectiveness in documentation [ 24 ].…”