Medical record abstraction in a hospital with paper-based records: experience of early career psychiatrists in northern Borneo

• Main Authors: Farah Ahmad Shahabuddin, Kheng, Yee Wah, Ryna Imma Buji, Nurul Syeema Zulkafli, Shea, Wah Lee, Hui, Lee Soon, Siau, Yun Yap, Vuii, Law, Loo, Jiann Lin
• Format: Article
• Language: English; English
• Published: Cambridge University Press 2020
• Subjects: RC435-571 Psychiatry
• Online Access: https://eprints.ums.edu.my/id/eprint/32506/1/Medical%20record%20abstraction%20in%20a%20hospital%20with%20paper-based%20records.pdf; https://eprints.ums.edu.my/id/eprint/32506/2/Medical%20record%20abstraction%20in%20a%20hospital%20with%20paper-based%20records%20_ABSTRACT.pdf; https://eprints.ums.edu.my/id/eprint/32506/; https://www.cambridge.org/core/journals/bjpsych-international/article/medical-record-abstraction-in-a-hospital-with-paperbased-records-experience-of-early-career-psychiatrists-in-northern-borneo/F01CFE31948019C5FACED6A8F642ECA7; http://dx.doi.org/10.1192/bji.2019.29

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.