THỰC TRẠNG VÀ THÁCH THỨC KHI TRIỂN KHAI HỒ SƠ BỆNH ÁN ĐIỆN TỬ TRONG QUẢN LÝ KHÁM CHỮA BỆNH TẠI BỆNH VIỆN ĐA KHOA THÀNH PHỐ CẦN THƠ NĂM 2023

Abstract

Background: Medical records are an essential tool in the care and treatment of patients. Transitioning to electronic medical records (EMRs) is becoming a mandatory task for all healthcare facilities. To effectively implement EMR applications tailored to the specific unit, hospitals need to have precise scientific justifications. The issue is the current usage status of paper medical records in healthcare providers and the attitudes of healthcare staff towards the transition to EMRs to determine the needs and plan interventions. Objectives: Description of the current status of medical record management, challenges, and related factors when implementing EMRs at Can Tho General Hospital from March 2023 to September 2023. Methods: A descriptive cross-sectional study was conducted on 250 medical staff who are directly managing and using medical records in medical examination and treatment at Can Tho General Hospital. We collected data on demography, the disadvantages of using traditional medical records in hospital management, and other related factors. Results: A majority of medical staff thought that the paper records required time-consuming reviewing medical records, with 69.2%. The biggest challenge in the medical examination and treatment process identified by healthcare staff is that patients have to go through numerous forms when admitted to the hospital (67.6%). From the hospital's perspective, a major difficulty in implementing innovations in healthcare management is the lack of financial resources (71.2%). Finally, this study has revealed the relation between the level of support for EMRs and education level (p < 0.05). Conclusions: Traditional medical records have many disadvantages that are difficult to handle because they exist in many related studies. We suggested that the hospital should apply EMRs to improve the quality of medical examination and treatment at the hospital. From a management perspective, when implementing the transition to EMRs, it is necessary to budget and seek appropriate funding for implementation, and when providing training and guidance, special attention should be paid to healthcare staff with educational levels below university.