Concordance of information in parallel electronic and paper based patient records

Objective: to evaluate the results of parallel use of both paper based and electronic patient records with respect to concordance of corresponding inf ormation in two continuously updated versions of the same records. Design: retrospective evaluation of patient records, comparing documentation in ele ctronic and paper based patient records. Setting: Department of Neurology i n a Norwegian university hospital using paper based and electronic patient records in parallel during migration towards completely electronic patient records. Material: electronic and paper based patient records of 90 randoml y selected patients visiting the department between 1 November 1997 and 30 April 1999. Results: seven percent of the electronic documents were signifi cantly different in some way from the corresponding paper documents. About 4-13% of the documents in the electronic record were missing; one percent w ere missing from the paper record. Conclusion: parallel use of electronic a nd paper based patient records has resulted in inconsistencies between the record systems in our setting. Documentation is missing in both the electro nic and paperbased records. When implementing electronic record systems int ended to operate in parallel with paperbased systems, focus should be on se curing the validity of all versions of the record. (C) 2001 Elsevier Scienc e Ireland Ltd. All rights reserved.