Journal articles: 'Medical care Medical Records'

1

ESSIN, DANIEL J., and CECELIA D. ESSIN. "Computerizing medical records." Critical Care Medicine 18, no. 1 (January 1990): 100–102. http://dx.doi.org/10.1097/00003246-199001000-00021.

Full text

APA, Harvard, Vancouver, ISO, and other styles

2

Md Zali, Mastura, Saiful Farik Mat Yatin, Mohd Razilan Abdul Kadir, Siti Noraini Mohd Tobi, Nurul Hanis Kamarudin, and Nik Nurul Emyliana Nik Ramlee. "Managing Medical Records in Specialist Medical Centres." International Journal of Engineering & Technology 7, no. 3.7 (July 4, 2018): 232. http://dx.doi.org/10.14419/ijet.v7i3.7.16358.

Full text

Abstract:

A collection of facts about a patient’s life and health history of past and present illnesses and treatments is known as medical records. The health professionals were contributing to record the patient’s care. The responsibility in managing daily records that produced by each of department is by the Medical Records Department. It is a department under clinical support services with activities including managing of patient records, patient information production, management of medical reports, and hospital statistics. This article aims to discuss the challenge associated with managing medical records in the organization and how to handle and manage it with the records management as a tool to mitigate risk. Therefore, it is likely to prompt further research by addressing existing gaps towards improving service delivery that can contribute to the body of knowledge in the field of records management and archives generally.

APA, Harvard, Vancouver, ISO, and other styles

3

Diamond, Edward, Kim French, Cynthia Gronkiewicz, and Marilyn Borkgren. "Electronic Medical Records." Chest 138, no. 3 (September 2010): 716–23. http://dx.doi.org/10.1378/chest.09-1328.

Full text

APA, Harvard, Vancouver, ISO, and other styles

4

Lehmann, Eldon D. "Electronic medical records help diabetes care." Lancet 348, no. 9028 (September 1996): 676. http://dx.doi.org/10.1016/s0140-6736(05)65089-1.

Full text

APA, Harvard, Vancouver, ISO, and other styles

5

Laugharne, Richard, and Claire Henderson. "Medical records: Patient-held records in mental health." Psychiatric Bulletin 28, no. 2 (February 2004): 51–52. http://dx.doi.org/10.1192/pb.28.2.51.

Full text

Abstract:

‘But don't they get lost?’ This is usually the first comment made when the authors mention the use of patient-held records (PHRs) to colleagues. Nevertheless, PHRs have been used in mental health care as well as several other settings, including services for diabetes, cancer, maternity and child health. In some of these services, including mental health, PHRs have been an addition to clinician held standard notes, whereas in others the patient holds the only record for their care. The main purposes of introducing PHRs have been to empower patients with a sense of ownership of their care and to improve communication, between both patients and clinicians, as well as between different clinicians involved in that person's care (Laugharne & Stafford, 1996).

APA, Harvard, Vancouver, ISO, and other styles

6

&NA;. "Electronic medical records." Nursing 42, no. 12 (December 2012): 6. http://dx.doi.org/10.1097/01.nurse.0000422666.28231.8d.

Full text

APA, Harvard, Vancouver, ISO, and other styles

7

Veronesi, James F. "Ethical Issues in Computerized Medical Records." Critical Care Nursing Quarterly 22, no. 3 (November 1999): 75–80. http://dx.doi.org/10.1097/00002727-199911000-00012.

Full text

APA, Harvard, Vancouver, ISO, and other styles

8

Tierney, William M. "Toward Electronic Medical Records That Improve Care." Annals of Internal Medicine 122, no. 9 (May 1, 1995): 725. http://dx.doi.org/10.7326/0003-4819-122-9-199505010-00011.

Full text

APA, Harvard, Vancouver, ISO, and other styles

9

Van Osdol, William, and Philip E. Johnsfon. "Quality Medical Records for Primary Care Centers." Journal For Healthcare Quality 14, no. 2 (March 1992): 44–45. http://dx.doi.org/10.1097/01445442-199203000-00014.

Full text

APA, Harvard, Vancouver, ISO, and other styles

10

Koppel, Ross, and Stephen B. Soumerai. "Personal Health Records and Medical Care Use." JAMA 309, no. 8 (February 27, 2013): 767. http://dx.doi.org/10.1001/jama.2013.378.

Full text

APA, Harvard, Vancouver, ISO, and other styles

11

Abdekhoda, Mohammadhiwa, Afsaneh Dehnad, Alireza Noruzi, Mahmodreza Gohari, and Maryam Ahmadi. "Applying Electronic Medical Records in health care." Applied Clinical Informatics 07, no. 02 (April 2016): 341–54. http://dx.doi.org/10.4338/aci-2015-11-ra-0165.

Full text

Abstract:

SummaryIn order to fulfill comprehensive interoperability and recognize the electronic medical records (EMRs’) benefits, physicians’ attitudes toward using and applying EMR must be recognized.The purpose of this study was to present an integrated model of applying EMRs by physicians.This was a cross sectional study in which a sample of 330 physicians working in hospitals affiliated to the Tehran University of medical sciences (TUMS) was selected. Physicians’ attitudes toward using and accepting EMR in health care have been analyzed by an integrated model of two classical theories i.e. technology acceptance model (TAM) and diffusion of innovation (DOI). The model was tested using an empirical survey. The final model was tested by structural equation modeling (SEM) and represented by Analysis of Moment Structures (AMOS).The results suggest that the hybrid model explains about 43 percent of the variance of using and accepting of EMRs (R2=0.43). The findings also evidenced that Perceived Usefulness (PU), Perceived Ease of Use (PEOU), Relative Advantage, Compatibility, Complicatedness and Trainability have direct and significant effect on physicians’ attitudes toward using and accepting EMRs. But concerning observeability, significant path coefficient was not reported.The integrated model supplies purposeful intuition for elucidates and anticipates of physicians’ behaviors in EMRs adoption. The study identified six relevant factors that affect using and applying EMRs that should be subsequently the major concern of health organizations and health policy makers.Citation: Abdekhoda M, Ahmadi M, Dehnad A, Noruzi A, Gohari M. Applying electronic medical records in health care: Physicians’ perspective.

APA, Harvard, Vancouver, ISO, and other styles

12

Lesk, Michael. "Electronic Medical Records: Confidentiality, Care, and Epidemiology." IEEE Security & Privacy 11, no. 6 (November 2013): 19–24. http://dx.doi.org/10.1109/msp.2013.78.

Full text

APA, Harvard, Vancouver, ISO, and other styles

13

Phillips, Krista, Chris Wheeler, Josh Campbell, and Alberto Coustasse. "Electronic Medical Records in Long-Term Care." Journal of Hospital Marketing & Public Relations 20, no. 2 (July 2010): 131–42. http://dx.doi.org/10.1080/15390942.2010.493377.

Full text

APA, Harvard, Vancouver, ISO, and other styles

14

Walker, James M. "Electronic Medical Records And Health Care Transformation." Health Affairs 24, no. 5 (September 2005): 1118–20. http://dx.doi.org/10.1377/hlthaff.24.5.1118.

Full text

APA, Harvard, Vancouver, ISO, and other styles

15

Jones, Robert G., Milan M. Mehta, and Robert K. McKinley. "Medical student access to electronic medical records in UK primary care." Education for Primary Care 22, no. 1 (January 1, 2011): 4–6. http://dx.doi.org/10.1080/14739879.2011.11493953.

Full text

APA, Harvard, Vancouver, ISO, and other styles

16

Mishra, Amit Kumar, Shiva Bhattarai, Partha Bhurtel, Navindra Raj Bista, P. Shrestha, Kabir Thakali, Prasan Banthia, and S. R. Pathak. "Need for Improvement of Medical Records." Journal of Nepal Medical Association 48, no. 174 (April 1, 2009): 103–6. http://dx.doi.org/10.31729/jnma.222.

Full text

Abstract:

Introduction: A medical record is a systematic documentation of a patient’s medical history and care for legal and future use. A poor quality medical record can negatively affect patient care and safety. The study aims to assess the adequacy of medical records in Bir Hospital, a central hospital.Methods:A cross-sectional study was conducted by analyzing consecutive discharge summaries of patients admitted during a 6 month period in a single unit of a tertiary care center. The discharge summary format of the hospital was taken as the standard and evaluation for adequacy of data entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies. Results: Patient’s condition at discharge was missing in 86 (66.15%). Patient’s address was missing in 21 (16.1%) cases. Almost all the discharge sheets lacked mailing address. Total 96 (73.8%) had use of abbreviations diagnosis. Age and sex were missing in 1 (0.76%). Doctor’s signature was illegible in 103 (79.3%) and missing in 2 (1.5%) summaries. Doctor’s name and their level/position were missing in 118 (90.76%) and 125 (96.1%) respectively. Total 126 patients (96.9%) were not given any instructions on discharge.Conclusions: The discharge summaries analyzed were seen to be inadequate especially in documenting course during the hospital stay, condition at discharge, appropriate instructions and the treating physician’s details. These can probably be addressed by introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and doctors should be trained to write legible, complete discharge summaries.Key Words: discharge, hospital, records, summaries

APA, Harvard, Vancouver, ISO, and other styles

17

Серегина, Ирина, Irina Seregina, Антон Колоколов, and Anton Kolokolov. "Medical records management in electronic format." Vestnik Roszdravnadzora 2019, no. 4 (August 22, 2019): 77–80. http://dx.doi.org/10.35576/article_5d651dbc7aa259.48167277.

Full text

Abstract:

The article deals with the legal significance of medical records management in the form of electronic document flow. Proper medical records management, which is necessary for the registration of the diagnostic and treatment process at all stages and for control of the quality of medical care delivery, is basis for evaluating of the organization of medical care and quality of its delivery.

APA, Harvard, Vancouver, ISO, and other styles

18

BROWN, HEATHER, and THERESE M. MADEY. "MEDICAL RECORDS SPECIALISTS RESPOND." Nursing 22, no. 4 (April 1992): 4. http://dx.doi.org/10.1097/00152193-199204000-00001.

Full text

APA, Harvard, Vancouver, ISO, and other styles

19

Astrid, M. "The Structure of Data in Medical Records." Yearbook of Medical Informatics 04, no. 01 (August 1995): 61–70. http://dx.doi.org/10.1055/s-0038-1638021.

Full text

Abstract:

Abstract:With the growing complexity of health care, patient data are more and more in demand for purposes such as research, education, postmarketing surveillance, quality assessment, and outcome analysis. Many of these purposes require patient data to be available in a structured, electronic format. Despite the rapid advances in computer technology, which allow patient data to be organized, analyzed, and shared, the majority of physicians still use paper medical records. Apparently, most physicians still perceive the paper record as being more suitable for their task than present day computerized versions. Both the shortcomings and the strengths of paper medical records have been identified and it proves difficult to design a computerized medical record that exploits the strengths of computers without loosing the advantages of the paper chart. The structure of patient data is an area of high interest, since structure determines how physicians, other health care workers, and patients may benefit from these data. An overview of research efforts in structuring patient data will offer insight in the problems that still impede a widespread use of the computerized patient record in clinical practice.

APA, Harvard, Vancouver, ISO, and other styles

20

Wardhina, Faizah, and Ermas Estiyana. "Management of Medical Record Unit to Preparing Accreditation at Primary Health Care." Jurnal Peduli Masyarakat 2, no. 4 (December 28, 2020): 227–36. http://dx.doi.org/10.37287/jpm.v2i4.309.

Full text

Abstract:

Puskesmas as the spearhead of public health services are required to always improve the quality of service delivery, both in the administration of primary health care management, clinical services, and primary health care program services. Accreditation is one of the efforts to ensure the quality improvement of primary health care services. Primary health care must compile medical records in accordance with the standards and criteria set by the first level health facility accreditation commission. It becomes a problem if the Puskesmas does not yet have human resources in the field of medical records, included the Karang Intan 2 primary health care. For this reason, primary health care need to increase the knowledge of its officers about managing medical record units and health information. The purpose of this community service activity is to increase the knowledge and skills of officers in managing the medical record unit at the Karang Intan 2 primary health care. This method of community service activities is carried out by provided learning about medical records to three medical record officers, then continued with guidance and consultation as well as monitored and evaluation to ensure a change for the better in the management of the medical record unit at the Karang Intan 2 primary health care. The result of this activity was an increased in the knowledge and skills of the medical record unit officers.

APA, Harvard, Vancouver, ISO, and other styles

21

Rodríguez-Vera, F. Javier, Y. Marín, A. Sánchez, C. Borrachero, and E. Pujol. "Illegible Handwriting in Medical Records." Journal of the Royal Society of Medicine 95, no. 11 (November 2002): 545–46. http://dx.doi.org/10.1177/014107680209501105.

Full text

Abstract:

In clinical records many items are handwritten and difficult to read. We examined clinical histories in a representative sample of case notes from a Spanish general hospital. Two independent observers assigned legibility scores, and a third adjudicated in case of disagreement. Defects of legibility such that the whole was unclear were present in 18 (15%) of 117 reports, and were particularly frequent in records from surgical departments. Through poor handwriting, much information in medical records is inaccessible to auditors, to researchers, and to other clinicians involved in the patient's care. If clinicians cannot be persuaded to write legibly, the solution must be an accelerated switch to computer-based systems.

APA, Harvard, Vancouver, ISO, and other styles

22

Smith, James P. "THE CARE CARD ? A NEW MEDICAL RECORDS' APPLICATION IN BRITISH HEALTH CARE." Journal of Advanced Nursing 14, no. 11 (November 1989): 893–94. http://dx.doi.org/10.1111/j.1365-2648.1989.tb01476.x.

Full text

APA, Harvard, Vancouver, ISO, and other styles

23

Sands, D. Z., D. M. Rind, and C. Safran. "Online Medical Records: A Decade of Experience." Methods of Information in Medicine 38, no. 04/05 (1999): 308–12. http://dx.doi.org/10.1055/s-0038-1634406.

Full text

Abstract:

AbstractThe electronic patient record at the Beth Israel Deaconess Medical Center has fundamentally changed the practice of medicine in ways that its developers never foresaw. This type of highly interactive and work flow enabled program is creating new collaborative roles for computers in complex organizations [4]. With the system able to supervise and monitor care, computers are able to perform many care coordination and documentation functions, freeing people to concentrate more on interpersonal interactions and provision of health care services. One of the challenges in the design of electronic patient records to assist health care providers is how to support collaboration while not requiring that people meet face-to-face. Moreover, a greater challenge for each of us as clinicians is to use this technology as a bridge (rather than a barrier) towards better patient-doctor relationships.

APA, Harvard, Vancouver, ISO, and other styles

24

Jorwekar, Harshal. "Medical Records Management with Decentralized Framework." International Journal for Research in Applied Science and Engineering Technology 9, no. VII (July 10, 2021): 193–200. http://dx.doi.org/10.22214/ijraset.2021.35703.

Full text

Abstract:

The mystery between the emotional improvement of medical information protection interest and long periods of administrative guideline has eased back advancement for electronic medical records (EMRs). In this paper, we propose a efficient, secure and decentralized Blockchain system for data privacy preserving and sharing. This manages confidentiality, authentication, data preserving and data sharing when handling sensitive information. We exploit consortium Blockchain and smart contracts to accomplish secure information storage and sharing, which forestalls information sharing without consent. The patient’s historical data, medical record, patient’s private information is very critical and needs to be stored and maintained securely. The proposed framework builds information security and eliminates the cost, time, and assets needed to deal with the medical care information records.

APA, Harvard, Vancouver, ISO, and other styles

25

Merz, Jon F., Pamela Sankar, and Simon S. Yoo. "Hospital Consent for Disclosure of Medical Records." Journal of Law, Medicine & Ethics 26, no. 3 (1998): 241–48. http://dx.doi.org/10.1111/j.1748-720x.1998.tb01425.x.

Full text

Abstract:

Physicians and other health care providers owe ethical and legal duties to patients to maintain the secrecy of the information learned during the course of patient care. This obligation is fulfilled by limiting access to such information to only those involved in the patient's care-that is, to those within the “circle of confidentiality.” As a general rule, providers may only disclose to others with the written prior consent of the patient. Exceptions may be “ethically and legally justified because of overriding social considerations,” when permitted or compelled by law. For example, eleven states permit providers to disclose identified records to approved researchers.’ Many states compel disclosure in cases where a patient threatens serious bodily harm to another; require reporting to health or law enforcement authorities of communicable diseases, gunshot or knife wounds, or child abuse; and mandate reporting of cancer or other health care cases to state registries (such as immunization, birth, and abortion).

APA, Harvard, Vancouver, ISO, and other styles

26

Tapia-Hernández, Marcos, Belén Cerda-Mendoza, and Esteban Parra-Valencia. "Medical records: the first challenge in health care." Medwave 16, no. 10 (November 9, 2016): e6601-e6601. http://dx.doi.org/10.5867/medwave.2016.10.6601.

Full text

APA, Harvard, Vancouver, ISO, and other styles

27

Lee, Woo Ryoung. "Electronic Medical Records in Neonatal Intensive Care Unit." Journal of the Korean Society of Neonatology 19, no. 1 (2012): 1. http://dx.doi.org/10.5385/jksn.2012.19.1.1.

Full text

APA, Harvard, Vancouver, ISO, and other styles

28

Palen, Ted E. "Personal Health Records and Medical Care Use—Reply." JAMA 309, no. 8 (February 27, 2013): 767. http://dx.doi.org/10.1001/jama.2013.384.

Full text

APA, Harvard, Vancouver, ISO, and other styles

29

Klumpp, Thomas R. "Electronic Medical Records and Quality of Cancer Care." Current Oncology Reports 15, no. 6 (October 5, 2013): 588–94. http://dx.doi.org/10.1007/s11912-013-0347-z.

Full text

APA, Harvard, Vancouver, ISO, and other styles

30

Chen, You, Abel N. Kho, David Liebovitz, Catherine Ivory, Sarah Osmundson, Jiang Bian, and Bradley A. Malin. "Learning bundled care opportunities from electronic medical records." Journal of Biomedical Informatics 77 (January 2018): 1–10. http://dx.doi.org/10.1016/j.jbi.2017.11.014.

Full text

APA, Harvard, Vancouver, ISO, and other styles

31

Gozali, Elahe, Marjan Ghazisaiedi, Malihe Sadeghi, and Reza Safdari. "Improvement of patient safety through implementation of electronic medical records." Medical Technologies Journal 1, no. 4 (November 29, 2017): 111–12. http://dx.doi.org/10.26415/2572-004x-vol1iss4p111-112.

Full text

Abstract:

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records, electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

APA, Harvard, Vancouver, ISO, and other styles

32

Silalahi, Rani Gartika Holivia, and Ermawaty Arisandi Siallagan. "PENGETAHUAN MAHASISWA DIII KEBIDANAN STIKES SANTA ELISABETH MEDAN TENTANG KELENGKAPAN PENCATATAN REKAM MEDIS." Elisabeth Health Jurnal 3, no. 2 (December 12, 2018): 58–62. http://dx.doi.org/10.52317/ehj.v3i2.247.

Full text

Abstract:

Hospitals as one of the health care facilities are required to make medical records. Medical records are written evidence of services provided by doctors that contain patient identity, examination, treatment, other actions and services that have been given to patients. Midwives as medical personnel who also provide health services have an obligation to make documentation of their midwifery care actions. Aim: This study aimed to analyze the relationship of midwifery DIII student knowledge about medical records with the completeness of filling in midwifery care documentation. Methode: This research was an analytic observational study with cross sectional design. The study population was all third level midwifery DIII students who served at Santa Elisabeth Hospital in Medan and were directly involved in filling in medical records. Data was obtained by observed the completeness of filling nursing care documentation in the medical record for the period August 1st-31st, 2018 and used a questionnaire to assess the level of knowledge of midwifery students about medical records (procedures for filling and legal aspects). Statistical test using Chi Square test. Result: In this study found significant results between variables of knowledge about the legal aspects of medical records (p = 0.011), procedures for filling nursing care documentation (p = 0.001). Variables of knowledge about medical records get significant results, namely (p = 0.004). Conclusion: There were a meaningful relationship between the knowledge of Midwifery DIII students about medical records with the completeness of filling in midwifery care documentation. Keywords: Students of DIII Midwifery, Knowledge, Medical Records, Midwifery Care Documentation.

APA, Harvard, Vancouver, ISO, and other styles

33

Chishima, Kayako, Yoshiki Toyokuni, Kondo Hisayoshi, Yuichi Koido, and Tatsuhiko Kubo. "Current Status of the Japanese Disaster Medical Record." Prehospital and Disaster Medicine 34, s1 (May 2019): s114. http://dx.doi.org/10.1017/s1049023x19002425.

Full text

Abstract:

Introduction:There was no common medical record used in disasters in Japan. At the 2011 Great East Japan Earthquake, medical teams used their own medical records instead of a unified format and operational rules. As a result, confusion occurred at the clinical practice site. The Joint Committee on Medical Records proposed a standard format of disaster medical records in February 2015. The Ministry of Health, Labor, and Welfare has issued the notification of states’ use of a standardized medical record for disaster in 2017. It was confirmed that standardized disaster medical records were used by each organization in the 2018 Western Japan torrential rain disaster and the Hokkaido Iburi Eastern Earthquake, but the actual condition of those records was not clarified.Methods:We sent a questionnaire to the local governments where the medical team worked in 2018 Western Japan torrential rain disaster and the Hokkaido Iburi Eastern Earthquake. In the questionnaire, we asked about the operation and management of standardized disaster medical records at the time of the disaster and also questioned future management methods.Results:There was no use of other medical records. Standardized medical records were used in all records. All records were managed and operated by the disaster medical headquarters responsible for health care and welfare. Standardized disaster medical records were recorded on paper. Evacuees included patients who moved from shelter to shelter or to temporary housing to get better living conditions. That created difficulties transferring records since it was recorded on paper and stored in medical headquarters. Some returning patients were checked by several medical teams, resulting in the creation of several medical records of the same patient’s condition. Future improvements and management of the recording process and record-keeping are required.

APA, Harvard, Vancouver, ISO, and other styles

34

Jafar, Anisa J. N., Ian Norton, Fiona Lecky, and Anthony D. Redmond. "A Literature Review of Medical Record Keeping by Foreign Medical Teams in Sudden Onset Disasters." Prehospital and Disaster Medicine 30, no. 2 (February 9, 2015): 216–22. http://dx.doi.org/10.1017/s1049023x15000102.

Full text

Abstract:

AbstractBackgroundMedical records are a tenet of good medical practice and provide one method of communicating individual follow-up arrangements, informing research data, and documenting medical intervention.MethodsThe objective of this review was to look at one source (the published literature) of medical records used by foreign medical teams (FMTs) in sudden onset disasters (SODs). The published literature was searched systematically for evidence of what medical records have been used by FMTs in SODs.FindingsThe style and content of medical records kept by FMTs in SODs varied widely according to the published literature. Similarly, there was great variability in practice as to what happens to the record and/or the data from the record following its use during a patient encounter. However, there was a paucity of published work comprehensively detailing the exact content of records used.InterpretationWithout standardization of the content of medical records kept by FMTs in SODs, it is difficult to ensure robust follow-up arrangements are documented. This may hinder communication between different FMTs and local medical teams (LMTs)/other FMTs who may then need to provide follow-up care for an individual. Furthermore, without a standard method of reporting data, there is an inaccurate picture of the work carried out. Therefore, there is not a solid evidence base for improving the quality of future response to SODs. Further research targeting FMTs and LMTs directly is essential to inform any development of an internationally agreed minimum data set (MDS), for both recording and reporting, in order that FMTs can reach the World Health Organization (WHO) standards for FMT practice.JafarAJN, NortonI, LeckyF, RedmondAD. A literature review of medical record keeping by foreign medical teams in sudden onset disasters. Prehosp Disaster Med. 2015;30(2):1-7.

APA, Harvard, Vancouver, ISO, and other styles

35

Malhotra, Naveen, and Marlieta Lassiter. "The Coming Age Of Electronic Medical Records: From Paper To Electronic." International Journal of Management & Information Systems (IJMIS) 18, no. 2 (March 28, 2014): 117. http://dx.doi.org/10.19030/ijmis.v18i2.8493.

Full text

Abstract:

Medical records, first developed in the fifth century, have remained virtually unchanged until the explosion of new technology in the mid-1960s. The National Space and Aeronautics Administrations development of computerized patient record (CPR) brought life to the electronic medical record (EMR) industry. Preventable deaths due to medical errors drew the attention of public and health care professionals to the need for increased patient safety and improved quality measures in medicine. With health care costs compromising 16-17% of the U.S. Gross Domestic Product, Congress passed legislation to financially support providers to adopt electronic medical record (EMR). As a result, future efforts will focus on the sharing of information among all health care stakeholders. Across the world, governments, technology companies, and care providers are collaborating efforts to make the EMR a reality.

APA, Harvard, Vancouver, ISO, and other styles

36

Mardyantari, Etik, Sandu Siyoto, and Sentot Imam Suprapto. "Analysis of Internal Customer Satisfaction Related to the Service of the Medical Record at Muhammadiyah Public Hospital Ponorogo." Journal for Quality in Public Health 4, no. 2 (April 30, 2021): 181–87. http://dx.doi.org/10.30994/jqph.v4i2.206.

Full text

Abstract:

The medical record department is one of the most important parts in the hospital's effort to provide excellent service to patients. The medical records section is indeed a part that is not directly involved in patient care, but other health workers need a medical record section in order to serve patients. The purpose of this study was to analyze internal customer satisfaction related to the service of the medical records department at Muhammadiyah Hospital Ponorogo. The research design used a descriptive quantitative research design. The sampling technique used was snowball sampling. The results showed that several obstacles were found, namely the speed of providing medical records, the accuracy of providing medical records, the management of KLPCM (Incomplete Filling Of Medical Records) and medical record officers who had medical record competence were still very limited. Improved services provided by the medical record department can increase internal customer satisfaction, and of course will have a direct impact on service to patients. nurses and hospital BPJS healthcare officers.

APA, Harvard, Vancouver, ISO, and other styles

37

Saputra, Tatang, and Erik Kurniadi. "SISTEM INFORMASI REKAM MEDIS PASIEN RAWAT JALAN DI UPTD PUSKESMAS KUNINGAN BERBASIS WEB." NUANSA INFORMATIKA 13, no. 2 (August 21, 2019): 19. http://dx.doi.org/10.25134/nuansa.v13i2.1949.

Full text

Abstract:

Puskesmas is a level 1 health facility. More than 40% of Indonesia's population uses health services at the Puskesmas. It is interesting that the Puskesmas is the health care provider that is closest to the community. Recording medical records of patients at the Kuningan Health Center is still done manually. Data search has time constraints. This happens because the same data is often found. Ineffective management of medical records will become a major problem in health services at the Puskesmas. This problem must be overcome so that the puskesmas has good data and information. One way to overcome this problem is to build a computerized medical record information system. Medical Record is a compilation of facts about the health and illness of a patient. Medical Records become a very important thing in the delivery of health services. Because the importance of a medical record, the author is interested in conducting research with the title "Information Systems for Outpatient Medical Records in UPTD Puskesmas Kuningan Web-Based". The medical record information system is expected to help improve the function of the Puskesmas as a place of health care. With the existence of a medical record system, each patient visit can be taken in a database making it easier for officers in the process of finding medical record data when needed. With the database, the compilation of patients forgetting to bring a treatment card can be done by searching the patient's data by the electronic officer. Making a report will be easier because it retrieves data that is done through the request system so as to facilitate the process and minimize errors in data management.Keywords: php, mysql, medical record, outpatient

APA, Harvard, Vancouver, ISO, and other styles

38

Aquino, M., J. M. Raboud, A. McGeer, K. Green, R. Chow, P. Dimoulas, M. Loeb, and D. Scales. "Accuracy of Healthcare Worker Recall and Medical Record Review for Identifying Infectious Exposures to Hospitalized Patients." Infection Control & Hospital Epidemiology 27, no. 7 (July 2006): 722–28. http://dx.doi.org/10.1086/504355.

Full text

Abstract:

Objective.To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting.Design.Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall.Setting.A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario.Patients.Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts.Results.Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient–HCW pairs were not recorded in patients' medical records.Conclusions.Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.

APA, Harvard, Vancouver, ISO, and other styles

39

Deckelbaum, Dan L., Ara J. Feinstein, Carl I. Schulman, Jeffrey S. Augenstein, Mary F. Murtha, Alan S. Livingstone, and Mark G. McKenney. "Electronic Medical Records and Mortality in Trauma Patients." Journal of Trauma: Injury, Infection, and Critical Care 67, no. 3 (September 2009): 634–36. http://dx.doi.org/10.1097/ta.0b013e3181a0fbce.

Full text

APA, Harvard, Vancouver, ISO, and other styles

40

Rowlands, Stella, Steven Coverdale, and Joanne Callen. "Documentation of clinical care in hospital patients’ medical records." Health Information Management Journal 45, no. 3 (July 26, 2016): 99–106. http://dx.doi.org/10.1177/1833358316639448.

Full text

Abstract:

Background: Clinical documentation is essential for communication between health professionals and the provision of quality care to patients. Objective: To examine medical students’ perspectives of their education in documentation of clinical care in hospital patients’ medical records. Method: A qualitative design using semi-structured interviews with fourth-year medical students was undertaken at a hospital-based clinical school in an Australian university. Results: Several themes reflecting medical students’ clinical documentation education emerged from the data: formal clinical documentation education using lectures and tutorials was minimal; most education occurred on the job by junior doctors and student’s expressed concerns regarding variation in education between teams and receiving limited feedback on performance. Respondents reported on the importance of feedback for their learning of disease processes and treatments. They suggested that improvements could be made in the timing of clinical documentation education and they stressed the importance of training on the job. Conclusion: On-the-job education with feedback in clinical documentation provides a learning opportunity for medical students and is essential in order to ensure accurate, safe, succinct and timely clinical notes.

APA, Harvard, Vancouver, ISO, and other styles

41

Frenzel, Jeanne E. "Using Electronic Medical Records to Teach Patient-Centered Care." American Journal of Pharmaceutical Education 74, no. 4 (September 2010): 71. http://dx.doi.org/10.5688/aj740471.

Full text

APA, Harvard, Vancouver, ISO, and other styles

42

O'Connor, M. Kevin. "Electronic Medical Records and Depression Screening in Primary Care." Primary Care Companion to The Journal of Clinical Psychiatry 05, no. 04 (August 1, 2003): 186. http://dx.doi.org/10.4088/pcc.v05n0409.

Full text

APA, Harvard, Vancouver, ISO, and other styles

43

Roumeliotis, Nadia, Geneviève Parisien, Sylvie Charette, Elizabeth Arpin, Fabrice Brunet, and Philippe Jouvet. "Reorganizing Care With the Implementation of Electronic Medical Records." Pediatric Critical Care Medicine 19, no. 4 (April 2018): e172-e179. http://dx.doi.org/10.1097/pcc.0000000000001450.

Full text

APA, Harvard, Vancouver, ISO, and other styles

44

Chou, David. "Electronic Medical Records: A Practical Guide for Primary Care." JAMA 305, no. 17 (May 4, 2011): 1810. http://dx.doi.org/10.1001/jama.2011.570.

Full text

APA, Harvard, Vancouver, ISO, and other styles

45

van Melle, Marije A., Dorien L. M. Zwart, Judith M. Poldervaart, Otto Jan Verkerk, Maaike Langelaan, Henk F. van Stel, and Niek J. de Wit. "Validity and reliability of a medical record review method identifying transitional patient safety incidents in merged primary and secondary care patients’ records." BMJ Open 8, no. 8 (August 2018): e018576. http://dx.doi.org/10.1136/bmjopen-2017-018576.

Full text

Abstract:

ObjectiveInadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity.DesignA retrospective medical record review study.Settings and participantsCombined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs.OutcomesTo assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs.ResultsThe reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3–28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen’s kappa −0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs.ConclusionThe reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.

APA, Harvard, Vancouver, ISO, and other styles

46

Lloyd, Geoffrey. "Medical Records: Copying letters to patients." Psychiatric Bulletin 28, no. 2 (February 2004): 57–59. http://dx.doi.org/10.1192/pb.28.2.57.

Full text

Abstract:

Access to medical information is going to be extended by recent Government proposals that patients who agree are sent copies of correspondence relevant to their illness and medical treatment. The National Health Service (NHS) Plan for England (Department of Health, 2000) has stated unequivocally that letters between clinicians about an individual patient's care will be copied to the patient as of right. No exceptions have been made and the plan did not suggest that patients suffering from a psychiatric illness are to be treated differently from any other group of patients. However, the Department of Health has recently stated its intention to fund a series of pilot projects to test some key concepts before the policy is fully implemented in 2004. A number of areas to be informed by pilot work have been identified. These include the style and content of letters, testing formats and language that patients find acceptable and particular issues concerning mental health, children and carers (www.doh.gov.uk/patientletters).

APA, Harvard, Vancouver, ISO, and other styles

47

Weaver, Meaghann S., Betty Anderson, Anne Cole, and Maureen E. Lyon. "Documentation of Advance Directives and Code Status in Electronic Medical Records to Honor Goals of Care." Journal of Palliative Care 35, no. 4 (July 7, 2019): 217–20. http://dx.doi.org/10.1177/0825859719860129.

Full text

Abstract:

Advance care planning is a process that supports conversations about the values that matter most to patients and their family members. The documentation of advance directives and code status in a patient’s electronic health record (EHR) is a critical step to ensure treatment preferences are honored in the medical care received. The current approach to advanced care planning documentation in electronic medical records often remains disparate within and across EHR systems. Without a standardized format for documentation or centralized location for documentation, advance directives and even code status content are often difficult to access within electronic medical records. This case report launched our palliative care team into partnership with the Information Technology team for implementation of a centralized, standardized, longitudinal, functional documentation of advance care planning and code status in the electronic medical record system.

APA, Harvard, Vancouver, ISO, and other styles

48

Goldberg, Ilene V. "Electronic Medical Records and Patient Privacy." Health Care Manager 18, no. 3 (March 2000): 63–69. http://dx.doi.org/10.1097/00126450-200018030-00009.

Full text

APA, Harvard, Vancouver, ISO, and other styles

49

Iskandar, Hary, Sabir Alwy, and Nurul Hudi. "KAJIAN YURIDIS PENGGUNAAN REKAM MEDIS UNTUK VERIFIKASI PEMBIAYAAN LAYANAN KESEHATAN." Medical Technology and Public Health Journal 2, no. 1 (August 24, 2018): 35–41. http://dx.doi.org/10.33086/mtphj.v2i1.315.

Full text

Abstract:

The use of patient medical records for hospital payment claims is in essence contrary to the medical records confidentiality rules. This study aims to review the judicial use of medical records in the verification of health care financing in the era of national health insurance. This research uses descriptive study method with normative juridical approach. Qualitative data comes from literature review such as primary, secondary and tertiary law. This study indicates that verifiers with the status of health workers have the legal authority to use patient information in medical records as they relate to the profession. Medical secrets can be opened in the context of quality control and health care costs. Quality control through medical audit, and cost control with health service utilization. This study recommends that verifiers be selected from medical personnel and therefore have the authority to open a medical record.

APA, Harvard, Vancouver, ISO, and other styles

50

Iskandar, Hary, Sabir Alwy, and Nurul Hudi. "KAJIAN YURIDIS PENGGUNAAN REKAM MEDIS UNTUK VERIFIKASI PEMBIAYAAN LAYANAN KESEHATAN." Medical Technology and Public Health Journal 2, no. 1 (August 24, 2018): 35–41. http://dx.doi.org/10.33086/mtphj.v2i1.765.

Full text

Abstract:

The use of patient medical records for hospital payment claims is in essence contrary to the medical records confidentiality rules. This study aims to review the judicial use of medical records in the verification of health care financing in the era of national health insurance. This research uses descriptive study method with normative juridical approach. Qualitative data comes from literature review such as primary, secondary and tertiary law. This study indicates that verifiers with the status of health workers have the legal authority to use patient information in medical records as they relate to the profession. Medical secrets can be opened in the context of quality control and health care costs. Quality control through medical audit, and cost control with health service utilization. This study recommends that verifiers be selected from medical personnel and therefore have the authority to open a medical record.

APA, Harvard, Vancouver, ISO, and other styles

Journal articles on the topic 'Medical care Medical Records'

Create a spot-on reference in APA, MLA, Chicago, Harvard, and other styles