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

Farah Ahmad ShahabuddinKheng Yee WahRyna Imma BujiNurul Syeema ZulkafliShea Wah LeeHui Lee SoonSiau Yun YapVuii LawJiann Lin Loo
Published in: BJPsych international (2019)
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.
Keyphrases
  • healthcare
  • deep learning
  • mental health
  • oxidative stress
  • adverse drug
  • medical students
  • smoking cessation