Computer-generated structured electronic medical records are preferable to conventional medical records for patients with acute abdominal pain - a prospective, double-blinded study.

OBJECTIVES: Structured medical records improve readability and ensure the inclusion of information necessary for correct diagnosis and treatment. This is the first study to assess the quality of computer-generated structured medical records by comparing them to conventional medical records on patients with acute abdominal pain. MATERIALS AND METHODS: A prospective double-blinded study was conducted in a tertiary referral center emergency department between January 2018 and June 2018. Patients were examined by emergency department physicians and by experience and inexperienced researcher. The researchers used a new electronical medical records system, which gathered data during the examination and the system generate structured medical records containing natural language. Conventional medical records dictated by physician and computer-generated medical records were compared by a group of independent clinicians. RESULTS: Ninety-nine patients were included. The overall quality of the computer-generated medical records was better than the quality of conventional human-generated medical records - the structure was similar or better in 99% of cases and the readability was similar or better in 86% of cases, p < 0.001. The quality of medical history, current illness, and findings of physical examinations were likewise better with the computer-generated recording. The results were similar when patients were examined by experienced or inexperienced researcher using the computer-generated recording. DISCUSSION: The quality of computer-generated structured medical records was superior to that of conventional medical records. The quality remained similar regardless of the researcher's level of experience. The system allows automatic risk scoring and easy access for quality control of patient care. We therefore consider that it would be useful in wider practice.

The use of abdominal imaging studies in children visiting emergency department was variable and unsystematic.

AIM: As imaging is used for various reasons in children with acute gastrointestinal complaints, we evaluated the indications and diagnostic yield of abdominal imaging, particularly ultrasound at emergency department (ED). METHODS: Indications and imaging reports of consecutive children who had undergone abdominal imaging in general, surgical and paediatric EDs in the Tampere University Hospital, Finland, in 2015 were collected. Symptoms, clinical findings, imaging indications and findings were categorised and further analysed. RESULTS: Altogether 394 imaging studies, 310 ultrasounds, 72 X-rays and 12 computed tomographies (CT), for 348 children (55% boys) aged 0-16.9 years, median 7.1 years, were performed. The most common indications for ultrasound were suspected appendicitis or infection (36%) and explanation for symptoms (32%), for X-ray suspected foreign body (39%) and obstruction (39%) and for CT trauma (50%). The cause of the symptoms or a clinically significant finding was established in 23% of ultrasounds, varying from 0% to 50% depending on the indication, symptoms and age. CONCLUSION: There was wide variation in the indications and yield of abdominal imaging. The clinical benefits, particularly those of US, were often questionable, even leading to delayed diagnosis and complications. More uniform imaging guidelines are needed in the paediatric ED.