Implementation and Impact of Psychiatric Electronic Medical Records in a Public Medical Center

Abstract

Objectives: This study describes the efforts to implement electronic charting in a large public psychiatric outpatient clinic with the objective to improve clinical documentation.

Methods: Data made available through the quality review process are utilized to evaluate the effectiveness of the electronic intervention. The study is a comparative analysis of the three years before and three years after the point of implementation of electronic charting.

Results: Statistical analyses indicate significant findings (p <.0001) in the comparison of the periods before and after implementation in terms of note completion and documentation of medication management, supporting the study's hypothesis that electronic intervention will improve the quality of clinical documentation.

Conclusions: This study contributes new knowledge to improve our understanding of the barriers and benefits of implementing and maintaining electronic charting in mental health settings.

Keywords: electronic charting; electronic medical records; psychiatric electronic medical records; quality improvement.

Figure 1

Trend Analysis of Intake Evaluation Notes after Implementation of Electronic Medical Records Notes: Generalized linear modeling was employed. In the period after implementation, items 1, 2, and 3 were all significant at p <.0001. Items shown in this graph are as follows: Item 1: The intake evaluation progress note documenting the completion of the intake evaluation was completed and co-signed by supervisors. Item 2: The provider's and supervisor's names are listed in the signature section of the progress note in the electronic chart. Item 3: The service procedure code, the face-to-face time, and total time used for intake are listed.