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. 2020 May;17(2):43-44.
doi: 10.1192/bji.2019.29. Epub 2019 Dec 2.

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

Farah Ahmad Shahabuddin  1 , Kheng Yee Wah  1 , Ryna Imma Buji  1 , Nurul Syeema Zulkafli  2 , Shea Wah Lee  2 , Hui Lee Soon  2 , Siau Yun Yap  1 , Vuii Law  3 , Jiann Lin Loo  4
Affiliations

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

Farah Ahmad Shahabuddin et al. BJPsych Int. 2020 May.

Abstract

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.

Keywords: MRA; Medical record abstraction; clinical research; documentation; paper-based medical record.

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Conflict of interest statement

Conflicts of interest: J.L.L. reports personal fees from Lundbeck, outside the submitted work.

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