Emergency Clinic Electronic Documentation Using Microsoft Access®

Abstract

Objective: 1) Assess the impact of using an electronic data collection form on medical documentation accuracy. 2) Test the model longitudinally for reliability and productivity.

Method: A prospective longitudinal audit 2008-2012 before and after introducing a Microsoft Access database as the sole form of documenting all ENT emergency clinic ancounters. Documentation was evaluated across 3 domains over 2 months. We then introduced the form for 2 months. The third arm is an automatic continuous audit loop.

Results: Data acquired were divided into demographics, clinical, and clerical covering 18 parameters. The first arm included 319 patients and showed 32% booking errors. 61% had missing or illegible information. Only 36% had the source of referral, and 41% had no clear outcome. These improved to 5% booking errors and 3% missing information during the second phasing arm (n = 330) with 98% compliance in using the new database, then to 1% and 0% in the third arm where 6000 cases were seen (chi-square, P < .001) in 16 out of 18 parameters.

Conclusion: The form has been in use for nearly 4 years. Information like the number of patients seen, source, waiting time, procedures carried out, and outcome are all available instantly in an easily presentable and auditable format. The form saves time and effort, helps with research, and improves in documentation and communication.