Journal articles: 'Medical records Medical records Medical informatics'

1

Tange, Huibert J., Arie Hasman, Pieter F. de Vries Robbé, and Harry C. Schouten. "Medical narratives in electronic medical records." International Journal of Medical Informatics 46, no. 1 (August 1997): 7–29. http://dx.doi.org/10.1016/s1386-5056(97)00048-8.

Full text

APA, Harvard, Vancouver, ISO, and other styles

2

Lian, Ping, Kangmei Chong, Xinhai Zhai, and Yi Ning. "The quality of medical records in teleconsultation." Journal of Telemedicine and Telecare 9, no. 1 (February 1, 2003): 35–41. http://dx.doi.org/10.1258/135763303321159675.

Full text

Abstract:

We collected and examined the medical records from telemedicine cases dealt with by the telemedicine centre of Shanghai Hospital No. 85. This centre handles the second largest number of teleconsultations in the entire network. There were 658 telemedicine cases in total. The medical records included the patient record in 599 cases (91%), transmitted images in 392 cases (60%), the consultant's opinion in 595 cases (90%) and a video-recording of the teleconsultation in 203 cases (31%). The quality of patient records was reviewed and found to be acceptable in 58% of cases. In total, 1794 radiology images (85% of all images) were transmitted via the telemedicine network. The consultant considered 352 of them (20%) to be unreadable on the screen (i.e. 80% of radiology images were considered to be acceptable). For optimum performance of telemedicine, the patient record and associated images should be delivered in advance and the relevant parts of the patient record should be available during a teleconsultation. Three aspects of the management of the medical records for teleconsultations are particularly important: multimedia collection, standardization of patient/record identification and classification, and information management.

APA, Harvard, Vancouver, ISO, and other styles

3

Gabrieli, Elmer R. "Automated medical office records." Journal of Medical Systems 11, no. 1 (February 1987): 59–68. http://dx.doi.org/10.1007/bf00992600.

Full text

APA, Harvard, Vancouver, ISO, and other styles

4

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

5

Quantin, Catherine, David-Olivier Jaquet-Chiffelle, Gouenou Coatrieux, Eric Benzenine, and François-André Allaert. "Medical record search engines, using pseudonymised patient identity: An alternative to centralised medical records." International Journal of Medical Informatics 80, no. 2 (February 2011): e6-e11. http://dx.doi.org/10.1016/j.ijmedinf.2010.10.003.

Full text

APA, Harvard, Vancouver, ISO, and other styles

6

Hawthorne, Kisha Hortman, and Lorraine Richards. "Personal health records: a new type of electronic medical record." Records Management Journal 27, no. 3 (November 20, 2017): 286–301. http://dx.doi.org/10.1108/rmj-08-2016-0020.

Full text

Abstract:

Purpose This paper examines existing research on the topic of personal health records (PHRs). Areas covered include PHR/patient portal, recordkeeping, preservation planning, access and provider needs for future reuse of health information. Patient and physician PHR use and functionality, as well as adoption facilitators and barriers, are also reviewed. Design/methodology/approach The paper engages in a review of relevant literature from a variety of subject domains, including personal information management, medical informatics, medical literature and archives and records management literature. Findings The review finds that PHRs are extensions of electronic records. In addition, it finds a lack of literature within archives and records management that may lead to a less preservation-centric examination of the new PHR technologies that are desirable for controlling the lifecycle of these important new records-type. Originality/value Although the issues presented by PHRs are issues that can best be solved with the use of techniques from records management, there is no current literature related to PHRs in the records management literature, and that offered in the medical informatics literature treats the stewardship aspects of PHRs as insurmountable. This paper offers an introduction to the aspects of PHRs that could fruitfully be examined in archives and records management.

APA, Harvard, Vancouver, ISO, and other styles

7

Yasunaga, Hideo, Tomoaki Imamura, Shintaro Yamaki, and Hiroyoshi Endo. "Computerizing medical records in Japan." International Journal of Medical Informatics 77, no. 10 (October 2008): 708–13. http://dx.doi.org/10.1016/j.ijmedinf.2008.03.005.

Full text

APA, Harvard, Vancouver, ISO, and other styles

8

Trimmer, Ken, Leigh W. Cellucci, Carla Wiggins, and William Woodhouse. "Electronic Medical Records." International Journal of Healthcare Information Systems and Informatics 4, no. 3 (July 2009): 55–68. http://dx.doi.org/10.4018/jhisi.2009070104.

Full text

APA, Harvard, Vancouver, ISO, and other styles

9

Bassøe, C. F., and J. E. Rasmussen. "Semantic Analysis of Medical Records." Methods of Information in Medicine 32, no. 01 (1993): 66–72. http://dx.doi.org/10.1055/s-0038-1634897.

Full text

Abstract:

Abstract:A program (LogStory) is described that was developed for the automatic semantic analysis of clinical narratives, stored in a computerized problem-oriented medical record (PROMED). The diagnoses were written in a free-text format during consultation, and later collected into diagnostic classes, e.g., diseases. A lexical parser automatically created dictionaries from the clinical narrative associated with each disease. Automatic (fuzzy) set operations were performed on the words associated with each class. The manifestations of 16 diseases were automatically extracted by pairwise operations on the word sets. The correlation between diseases and corresponding signs, symptoms and treatment was highly significant (p <0.001). Applying the difference operation on diseases with disjunct sets of clinical findings allowed the recovery of disease-specific knowledge. The evolution of a disease was accounted for, and the system was able to generalize its findings. The PROMED-LogStory concept enables the processing of natural language and may be a powerful tool for knowledge acquisition and clinical research.

APA, Harvard, Vancouver, ISO, and other styles

10

Murphy, Cynthia A., Kelly Merriman, Cindy Zabka, Marcella Penick, and Precy Villamayor. "Patient-Entered Electronic Healthcare Records With Electronic Medical Record Integration." CIN: Computers, Informatics, Nursing 26, no. 5 (September 2008): 302. http://dx.doi.org/10.1097/01.ncn.0000304828.47262.6c.

Full text

APA, Harvard, Vancouver, ISO, and other styles

11

Barrows, R. C., and P. D. Clayton. "Privacy, Confidentiality, and Electronic Medical Records." Journal of the American Medical Informatics Association 3, no. 2 (March 1, 1996): 139–48. http://dx.doi.org/10.1136/jamia.1996.96236282.

Full text

APA, Harvard, Vancouver, ISO, and other styles

12

Kartoun, Uri. "Advancing informatics with electronic medical records bots (EMRBots)." Software Impacts 2 (November 2019): 100006. http://dx.doi.org/10.1016/j.simpa.2019.100006.

Full text

APA, Harvard, Vancouver, ISO, and other styles

13

Sung, MinDong, SungJun Park, Sungjae Jung, Eunsol Lee, Jaehoon Lee, and Yu Rang Park. "Developing a Mobile App for Monitoring Medical Record Changes Using Blockchain: Development and Usability Study." Journal of Medical Internet Research 22, no. 8 (August 14, 2020): e19657. http://dx.doi.org/10.2196/19657.

Full text

Abstract:

Background Although we are living in an era of transparency, medical documents are often still difficult to access. Blockchain technology allows records to be both immutable and transparent. Objective Using blockchain technology, the aim of this study was to develop a medical document monitoring system that informs patients of changes to their medical documents. We then examined whether patients can effectively verify the monitoring of their primary care clinical medical records in a system based on blockchain technology. Methods We enrolled participants who visited two primary care clinics in Korea. Three substudies were performed: (1) a survey of the recognition of blockchain medical records changes and the digital literacy of participants; (2) an observational study on participants using the blockchain-based mobile alert app; and (3) a usability survey study. The participants’ medical documents were profiled with HL7 Fast Healthcare Interoperability Resources, hashed, and transacted to the blockchain. The app checked the changes in the documents by querying the blockchain. Results A total of 70 participants were enrolled in this study. Considering their recognition of changes to their medical records, participants tended to not allow these changes. Participants also generally expressed a desire for a medical record monitoring system. Concerning digital literacy, most questions were answered with “good,” indicating fair digital literacy. In the second survey, only 44 participants—those who logged into the app more than once and used the app for more than 28 days—were included in the analysis to determine whether they exhibited usage patterns. The app was accessed a mean of 5.1 (SD 2.6) times for 33.6 (SD 10.0) days. The mean System Usability Scale score was 63.21 (SD 25.06), which indicated satisfactory usability. Conclusions Patients showed great interest in a blockchain-based system to monitor changes in their medical records. The blockchain system is useful for informing patients of changes in their records via the app without uploading the medical record itself to the network. This ensures the transparency of medical records as well as patient empowerment.

APA, Harvard, Vancouver, ISO, and other styles

14

Pantazos, Kostas, Soren Lauesen, and Soren Lippert. "Preserving medical correctness, readability and consistency in de-identified health records." Health Informatics Journal 23, no. 4 (May 19, 2016): 291–303. http://dx.doi.org/10.1177/1460458216647760.

Full text

Abstract:

A health record database contains structured data fields that identify the patient, such as patient ID, patient name, e-mail and phone number. These data are fairly easy to de-identify, that is, replace with other identifiers. However, these data also occur in fields with doctors’ free-text notes written in an abbreviated style that cannot be analyzed grammatically. If we replace a word that looks like a name, but isn’t, we degrade readability and medical correctness. If we fail to replace it when we should, we degrade confidentiality. We de-identified an existing Danish electronic health record database, ending up with 323,122 patient health records. We had to invent many methods for de-identifying potential identifiers in the free-text notes. The de-identified health records should be used with caution for statistical purposes because we removed health records that were so special that they couldn’t be de-identified. Furthermore, we distorted geography by replacing zip codes with random zip codes.

APA, Harvard, Vancouver, ISO, and other styles

15

Cora Garcia, Angela, Gary C. David, and Donald Chand. "Understanding the work of medical transcriptionists in the production of medical records." Health Informatics Journal 16, no. 2 (June 2010): 87–100. http://dx.doi.org/10.1177/1460458210361936.

Full text

APA, Harvard, Vancouver, ISO, and other styles

16

Kulikowski, C., A. Bohne, K. Ganser, R. Haux, P. Knaup, C. Maier, A. Michel, R. Singer, A. C. Wolff, and E. Ammenwerth. "Medical Imaging Informatics and Medical Informatics: Opportunities and Constraints." Methods of Information in Medicine 41, no. 02 (2002): 183–89. http://dx.doi.org/10.1055/s-0038-1634304.

Full text

Abstract:

Summary Objectives: The Yearbook of Medical Informatics is published annually by the International Medical Informatics Association (IMIA) and contains a selection of recent excellent papers on medical informatics research (http://www.yearbook.uni-hd.de). The 2002 Yearbook of Medical Informatics took as its theme the topic of Medical Imaging Informatics. In this paper, we will summarize the contributions of medical informatics researchers to the development of medical imaging informatics, discuss challenges and opportunities of imaging informatics, and present the lessons learned from the IMIA Yearbook 2002. Results and Conclusions: Medical informatics researchers have contributed to the development of medical imaging methods and systems since the inception of this field approximately 40 years ago. The Yearbook presents selected papers and reviews on this important topic.In addition, as usual, the Yearbook 2002 also contains a variety of papers and reviews on other subjects relevant to medical informatics, such as Bioinformatics, Computer-supported education, Health and clinical management, Health information systems, Knowledge processing and decision support, Patient records, and Signal processing.

APA, Harvard, Vancouver, ISO, and other styles

17

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

18

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

19

Zarcadoolas, Christina, Wendy L. Vaughon, Sara J. Czaja, Joslyn Levy, and Maxine L. Rockoff. "Consumers' Perceptions of Patient-Accessible Electronic Medical Records." Journal of Medical Internet Research 15, no. 8 (August 26, 2013): e168. http://dx.doi.org/10.2196/jmir.2507.

Full text

APA, Harvard, Vancouver, ISO, and other styles

20

Uzuner, O., I. Goldstein, Y. Luo, and I. Kohane. "Identifying Patient Smoking Status from Medical Discharge Records." Journal of the American Medical Informatics Association 15, no. 1 (January 1, 2008): 14–24. http://dx.doi.org/10.1197/jamia.m2408.

Full text

APA, Harvard, Vancouver, ISO, and other styles

21

Handy, J., I. Hunter, and R. Whiddett. "User acceptance of inter-organizational electronic medical records." Health Informatics Journal 7, no. 2 (June 2001): 103–7. http://dx.doi.org/10.1177/146045820100700208.

Full text

APA, Harvard, Vancouver, ISO, and other styles

22

Pereira, Luís, Rui Rijo, Catarina Silva, and Ricardo Martinho. "Text Mining Applied to Electronic Medical Records." International Journal of E-Health and Medical Communications 6, no. 3 (July 2015): 1–18. http://dx.doi.org/10.4018/ijehmc.2015070101.

Full text

Abstract:

The analysis of medical records is a major challenge, considering they are generally presented in plain text, have a very specific technical vocabulary and are nearly always unstructured. It is an interdisciplinary work that requires knowledge from several fields. The analysis may have several goals, such as assistance on clinical decision, classification of medical procedures, and to support hospital management decisions. This work presents the concepts involved, the relevant existent related work, and the main open issues for future research within the analysis of electronic medical records, using data and text mining techniques. It provides a comprehensive contextualization to all those who wish to perform an analytical work of medical records, enabling the identification of fruitful research fields. With the digitalization of medical records and the large amount of medical data available, this is an area of wide research potential.

APA, Harvard, Vancouver, ISO, and other styles

23

Christensen, Dale B., Barbara Williams, Harold I. Goldberg, Diane P. Martin, Ruth Engelberg, and James P. LoGerfo. "Comparison of Prescription and Medical Records in Reflecting Patient Antihypertensive Drug Therapy." Annals of Pharmacotherapy 28, no. 1 (January 1994): 99–104. http://dx.doi.org/10.1177/106002809402800119.

Full text

Abstract:

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n=982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5–8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

APA, Harvard, Vancouver, ISO, and other styles

24

Rector, A. L., W. A. Nowlan, and S. Kay. "Foundations for an Electronic Medical Record." Methods of Information in Medicine 30, no. 03 (1991): 179–86. http://dx.doi.org/10.1055/s-0038-1634836.

Full text

Abstract:

AbstractGiven the many efforts currently under way to develop standards for electronic medical records, it is important to step back and reexamine the fundamental principles which should underlie a model of the electronic medical record. This paper presents an analysis based on the experience in developing the PEN & PAD prototype clinical workstation. The fundamental contention is that the requirements for a medical record must be grounded in its use for patient care. The basic requirement is that it be a faithful record of what clinicians have heard, seen, thought, and done. The other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view. We use the criteria developed to re-examine Weed’s Problem Oriented Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support.

APA, Harvard, Vancouver, ISO, and other styles

25

Croll, P., B. Li, C. P. Wong, S. Gogia, A. Faud, Y. S. Kwak, S. Chu, et al. "Survey on Medical Records and EHR in Asia-Pacific Region." Methods of Information in Medicine 50, no. 04 (2011): 386–91. http://dx.doi.org/10.3414/me11-02-0002.

Full text

Abstract:

SummaryObjectives: To clarify health record background information in the Asia-Pacific region, for planning and evaluation of medical information systems.Methods: The survey was carried out in the summer of 2009. Of the 14 APAMI (Asia-Pacific Association for Medical Informatics) delegates 12 responded which were Australia, China, Hong Kong, India, Indonesia, Japan, Korea, New Zealand, the Philippines, Singapore, Thailand, and Taiwan.Results: English is used for records and education in Australia, Hong Kong, India, New Zealand, the Philippines, Singapore and Taiwan. Most of the countries/regions are British Commonwealth. Nine out of 12 delegates responded that the second purpose of medical records was for the billing of medical services. Seven out of nine responders to this question answered that the second purpose of EHR (Electronic Health Records) was healthcare cost cutting. In Singapore, a versatile resident ID is used which can be applied to a variety of uses. Seven other regions have resident IDs which are used for a varying range of purposes. Regarding healthcare ID, resident ID is simply used as healthcare ID in Hong Kong, Singapore and Thailand. In most cases, disclosure of medical data with patient’s name identified is allowed only for the purpose of disease control within a legal framework and for disclosure to the patient and referred doctors. Secondary use of medical information with the patient’s identification anonymized is usually allowed in particular cases for specific purposes.Conclusion: This survey on the health record background information has yielded the above mentioned results. This information contributes to the planning and evaluation of medical information systems in the Asia-Pacific region.

APA, Harvard, Vancouver, ISO, and other styles

26

Frénot, S., and F. Laforest. "Medical Record Management Systems: Criticisms and New Perspectives." Methods of Information in Medicine 38, no. 02 (1999): 89–95. http://dx.doi.org/10.1055/s-0038-1634179.

Full text

Abstract:

AbstractThe first generation of computerized medical records stored the data as text, but these records did not bring any improvement in information manipulation. The use of a relational database management system (DBMS) has largely solved this problem as it allows for data requests by using SQL. However, this requires data structuring which is not very appropriate to medicine. Moreover, the use of templates and icon user interfaces has introduced a deviation from the paper-based record (still existing). The arrival of hypertext user interfaces has proven to be of interest to fill the gap between the paper-based medical record and its electronic version. We think that further improvement can be accomplished by using a fully document-based system. We present the architecture, advantages and disadvantages of classical DBMS-based and Web/DBMS-based solutions. We also present a document-based solution and explain its advantages, which include communication, security, flexibility and genericity.

APA, Harvard, Vancouver, ISO, and other styles

27

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

28

Ancker, Jessica S., Marianne Sharko, Matthew Hong, Hannah Mitchell, and Lauren Wilcox. "Should parents see their teen’s medical record? Asking about the effect on adolescent–doctor communication changes attitudes." Journal of the American Medical Informatics Association 25, no. 12 (September 20, 2018): 1593–99. http://dx.doi.org/10.1093/jamia/ocy120.

Full text

Abstract:

Abstract Objective Parents routinely access young children’s medical records, but medical societies strongly recommend confidential care during adolescence, and most medical centers restrict parental records access during the teen years. We sought to assess public opinion about adolescent medical privacy. Materials and Methods The Cornell National Social Survey (CNSS) is an annual nationwide public opinion survey. We added questions about a) whether parents should be able to see their 16-year-old child’s medical record, and b) whether teens would avoid discussing sensitive issues (sex, alcohol) with doctors if parents could see the record. Hypothesizing that highlighting the rationale for adolescent privacy would change opinions, we conducted an experiment by randomizing question order. Results Most respondents (83.0%) believed that an adolescent would be less likely to discuss sensitive issues with doctors with parental medical record access; responses did not differ by question order (P = .29). Most also believed that parents should have access to teens’ records, but support for parental access fell from 77% to 69% among those asked the teen withholding question first (P = .01). Conclusions Although medical societies recommend confidential care for adolescents, public opinion is largely in favor of parental access. A brief “nudge,” asking whether parental access might harm adolescent–doctor communication, increased acceptance of adolescent confidentiality, and could be part of a strategy to prepare parents for electronic patient portal policies that medical centers impose at the beginning of adolescence.

APA, Harvard, Vancouver, ISO, and other styles

29

Shuaib, Waqas, Julia Marielly Suarez, Juan David Romero, Carlos Dillon Pamello, Richard Alweis, Aizaaz Ali Khan, Syed Raza Shah, Hassan Shahid, Serge B. PierreCharles, and Laura Rosemary Sanchez. "Transforming patient care by introducing an electronic medical records initiative in a developing country." Health Informatics Journal 22, no. 4 (July 26, 2016): 975–83. http://dx.doi.org/10.1177/1460458215589204.

Full text

Abstract:

The incorporation of an electronic medical record into patient care is a priority in developed countries, but faces significant obstacles for adoption in developing countries. The goal of our study was to define and assess the efficiency of a personalized intervention on village physicians’ use of electronic medical records in rural community health services of underprivileged areas. Six towns were selected with two bordering local health stations from each town. One was randomly given to the intervention group and the other to the control group. A structured on-site intervention was provided to village physicians in the intervention group, for 7 months. The results showed that in the intervention group, the percentage of households with complete records increased. The percentage of clinic medical records and complete child vaccination in the intervention group also increased from 2 to 14 percent (p = <0.05) and from 10 to 23 percent (p = 0.05), respectively. Our investigation demonstrated that on-site education, supervision, and technical support directly correlate with improved use of electronic medical record. Our results report the challenges in implementing such a system and the steps being taken to enhance likelihood of sustainability.

APA, Harvard, Vancouver, ISO, and other styles

30

Purves, I. N., and S. Kay. "Medical Records and Other Stories: a Narratological Framework." Methods of Information in Medicine 35, no. 02 (April 1996): 72–87. http://dx.doi.org/10.1055/s-0038-1634648.

Full text

Abstract:

AbstractA new model of the medical record is introduced which can incorporate context, structure, process and use of the medical record within a single narratological framework. It is claimed that the analysis of narrative and, in particular, the study of the story metaphor can provide a theoretical model which provides coherence within the broad discipline of Medical Informatics. It is argued that this framework maintains different levels of abstraction, is useful for teaching and clinical practice, and that its concepts can be readily understood by those in both lay and technical healthcare professions.

APA, Harvard, Vancouver, ISO, and other styles

31

Allen-Graham, Judith, Lauren Mitchell, Natalie Heriot, Roksana Armani, David Langton, Michele Levinson, Alan Young, Julian A. Smith, Tom Kotsimbos, and John W. Wilson. "Electronic health records and online medical records: an asset or a liability under current conditions?" Australian Health Review 42, no. 1 (2018): 59. http://dx.doi.org/10.1071/ah16095.

Full text

Abstract:

Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information. Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital’s current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary. Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution. Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services. What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This causes inefficiencies in the recall of patient information and can potentially lead to incidences of adverse drug events. What does this paper add? This paper supports the concept of a shared medical record system using 200 audited patient records across five Victorian metropolitan hospitals, comparing the current information systems in place for healthcare practitioners to retrieve data. This research identifies the degree of concordance between these sources of information and in doing so, areas for improvement. What are the implications for practitioners? Implications of this research are the improvements in the quality, storage and accessibility of medical data in Australian healthcare systems. This is a relevant issue in the current Australian environment where no guidelines exist across the board in medical history documentation or in the distribution of discharge summaries to other healthcare providers (general practitioners, etc).

APA, Harvard, Vancouver, ISO, and other styles

32

Dolan, Bridget. "Medical records: Disclosing confidential clinical information." Psychiatric Bulletin 28, no. 2 (February 2004): 53–56. http://dx.doi.org/10.1192/pb.28.2.53.

Full text

Abstract:

Although our courts remain reluctant to create any general right to privacy, whether under common law or even by virtue of statutes such as the Human Rights Act 1998, one important aspect of privacy is recognised in common law – that of the confidentiality of medical information.

APA, Harvard, Vancouver, ISO, and other styles

33

Cahyani, Prilian, and Astutik Astutik. "Criminal Liability for Misuse of Electronic Medical Records in Health Services." SOEPRA 5, no. 2 (April 2, 2020): 215. http://dx.doi.org/10.24167/shk.v5i2.2431.

Full text

Abstract:

Electronic medical records (RME) have been used in hospitals as a substitute for or complementary to medical records in the form of paper. The obligation to make medical records is the responsibility of every doctor or dentist in carrying out the medical practice. However, the use of electronic-based medical records does not rule out the possibility of raising problems in the field of law, if some abuse it. This will raise the issue of who has the obligation to take responsibility. The problem is the background of the author to write in an article with the title "Accountability for the Misuse of Electronic Medical Record Abuse in Health Services". The formulation of the problem in this article is: 1) Setting an electronic medical record; 2) Criminal liability for the misuse of electronic medical records. The research method used is normative legal research with a statutory approach and a conceptual approach. From the discussion, it can be seen that in Indonesia the obligation to make medical records is specifically regulated in the Medical Practice Law. Furthermore, in the Ministry of Health No. 269 / MENKES / PER / III / 2008 especially Article 2 paragraph 2 states that medical records can be made electronically. However, to date, no specific regulations are governing electronic medical records. The use of electronic systems in medical records makes it necessary to heed the provisions of Law No. 11 of 2008 concerning Electronic Information and Transactions. The party who has the responsibility for the misuse of the Electronic Medical Record covers people who in this case are medical personnel or certain health workers. Hospitals can also be held responsible for the misuse of electronic medical records.

APA, Harvard, Vancouver, ISO, and other styles

34

Yu, Yao-Chang, To-Yeh Huang, and Ting-Wei Hou. "Forward Secure Digital Signature for Electronic Medical Records." Journal of Medical Systems 36, no. 2 (May 6, 2010): 399–406. http://dx.doi.org/10.1007/s10916-010-9484-1.

Full text

APA, Harvard, Vancouver, ISO, and other styles

35

Weerasinghe, D., K. Elmufti, V. Rakocevic, and M. Rajarajan. "Patient Privacy Protection Using Anonymous Access Control Techniques." Methods of Information in Medicine 47, no. 03 (2008): 235–40. http://dx.doi.org/10.3414/me9116.

Full text

Abstract:

Summary Objective: The objective of this study is to develop a solution to preserve security and privacy in a healthcare environment where health-sensitive information will be accessed by many parties and stored in various distributed databases. The solution should maintain anonymous medical records and it should be able to link anonymous medical information in distributed databases into a single patient medical record with the patient identity. Methods: In this paper we present a protocol that can be used to authenticate and authorize patients to healthcare services without providing the patient identification. Healthcare service can identify the patient using separate temporary identities in each identification session and medical records are linked to these temporary identities. Temporary identities can be used to enable record linkage and reverse track real patient identity in critical medical situations. Results: The proposed protocol provides main security and privacy services such as user anonymity, message privacy, message confidentiality, user authentication, user authorization and message replay attacks. The medical environment validates the patient at the healthcare service as a real and registered patient for the medical services. Using the proposed protocol, the patient anonymous medical records at different healthcare services can be linked into one single report and it is possible to securely reverse track anonymous patient into the real identity. Conclusion: The protocol protects the patient privacy with a secure anonymous authentication to healthcare services and medical record registries according to the European and the UK legislations, where the patient real identity is not disclosed with the distributed patient medical records.

APA, Harvard, Vancouver, ISO, and other styles

36

Nygren, E., M. Johnson, and P. Henriksson. "Reading the medical record. II. Design of a human-computer interface for basic reading of computerized medical records." Computer Methods and Programs in Biomedicine 39, no. 1-2 (September 1992): 13–25. http://dx.doi.org/10.1016/0169-2607(92)90054-b.

Full text

APA, Harvard, Vancouver, ISO, and other styles

37

Cahyaharnita, Rezky Ami. "Synchronization of Electronic Medical Record Implementation Guidelines in National E-Health Strategies." SOEPRA 5, no. 2 (April 2, 2020): 209. http://dx.doi.org/10.24167/shk.v5i2.2430.

Full text

Abstract:

Medical records are made in writing, complete and clear or electronically. Medical records are the basis of medical services to patients. Paper medical records increase the amount of paper waste in Indonesia. A national e-health strategy is a comprehensive approach to efforts in the national health sector. Electronic medical records are more effective because of better time management. The formulation of the problem in this article covers the reasons, criteria, and implementation of electronic medical records. The research method used is descriptive qualitative research with a statute approach. The criteria for a good electronic medical record are integrated data from various sources, data collected at the service point, and supporting service providers in decision making. The expected electronic medical record is to be integrated with the health service facility information system program without neglecting the confidentiality aspect. Therefore, the government needs to make regulations on the technical implementation of electronic medical records.

APA, Harvard, Vancouver, ISO, and other styles

38

Elkefi, Safa, Zhongyuan Yu, and Onur Asan. "Online Medical Record Nonuse Among Patients: Data Analysis Study of the 2019 Health Information National Trends Survey." Journal of Medical Internet Research 23, no. 2 (February 22, 2021): e24767. http://dx.doi.org/10.2196/24767.

Full text

Abstract:

Background Online medical records are being used to organize processes in clinical and outpatient settings and to forge doctor-patient communication techniques that build mutual understanding and trust. Objective We aimed to understand the reasons why patients tend to avoid using online medical records and to compare the perceptions that patients have of online medical records based on demographics and cancer diagnosis. Methods We used data from the Health Information National Trends Survey Cycle 3, a nationally representative survey, and assessed outcomes using descriptive statistics and chi-square tests. The patients (N=4328) included in the analysis had experienced an outpatient visit within the previous 12 months and had answered the online behavior question regarding their use of online medical records. Results Patients who were nonusers of online medical records consisted of 58.36% of the sample (2526/4328). The highest nonuser rates were for patients who were Hispanic (460/683, 67.35%), patients who were non-Hispanic Black (434/653, 66.46%), and patients who were older than 65 years (968/1520, 63.6%). Patients older than 65 years were less likely to use online medical records (odds ratio [OR] 1.51, 95% CI 1.24-1.84, P<.001). Patients who were White were more likely to use online medical records than patients who were Black (OR 1.71, 95% CI 1.43-2.05, P<.001) or Hispanic (OR 1.65, 95% CI 1.37-1.98, P<.001). Patients who were diagnosed with cancer were more likely to use online medical records compared to patients with no cancer (OR 1.31, 95% CI 1.11-1.55, 95% CI 1.11-1.55, P=.001). Among nonusers, older patients (≥65 years old) preferred speaking directly to their health care providers (OR 1.76, 95% CI 1.35-2.31, P<.001), were more concerned about privacy issues caused by online medical records (OR 1.79, 95% CI 1.22-2.66, P<.001), and felt uncomfortable using the online medical record systems (OR 10.55, 95% CI 6.06-19.89, P<.001) compared to those aged 18-34 years. Patients who were Black or Hispanic were more concerned about privacy issues (OR 1.42, 1.09-1.84, P=.007). Conclusions Studies should consider social factors such as gender, race/ethnicity, and age when monitoring trends in eHealth use to ensure that eHealth use does not induce greater health status and health care disparities between people with different backgrounds and demographic characteristics.

APA, Harvard, Vancouver, ISO, and other styles

39

Samsir and Syaiful Zuhri Harahap. "Application Design Resume Medical By Using Microsoft Visual Basic.Net 2010 At The Health Center Appointments." International Journal of Science, Technology & Management 1, no. 1 (May 27, 2020): 14–20. http://dx.doi.org/10.46729/ijstm.v1i1.5.

Full text

Abstract:

In implementing health services, puskesmas must document all actions and treatments that are given to patients in a document called Medical Records. According to Minister of Health Regulation No.269 / MENKES / PER / III / 2008 article 1 (1), medical records are files containing notes and documents about patient identities. Medical records are of good quality if the medical record is accurate, complete, trustworthy, valid and timely. One form of management in Medical Records is reporting. According to Minister of Health Regulation No.269 / MENKES / PER / III / 2008 article 1 (1), Medical Record is a file that contains notes and documents about patient identity, examinations, actions, and other services that have been given to patients. In the statement, all information about a patient has been reflected which will be made the basis for determining further actions in services and other medical actions given to a patient who comes to the community health center. The Medical Record is said to be of high quality if the Medical Record is accurate, complete, trustworthy, valid and timely. The Medical Record Installation has activities such as registration, data processing, and storage. One form of processing data in medical records is the existence of assembling activities. Assembling is an assembling activity compiling empty Medical Record forms and storing them into Medical Records, ready to use neatly arranged both in terms of quality and quality.

APA, Harvard, Vancouver, ISO, and other styles

40

Muchlis, Ahmad, and Rifa Aulia Ramadhanty. "Correlation Between Medical Information Completeness and Accuracy of The Diagnosis Code for Upper Respiratory Tract Infection and Hypertension Based on ICD-10 in Medical Record at Cibening Health Center." Muhammadiyah Medical Journal 2, no. 1 (May 31, 2021): 1. http://dx.doi.org/10.24853/mmj.2.1.1-6.

Full text

Abstract:

Background: Completeness of patient medical information in medical records is one indicator in assessing the quality of health services. Complete and accurate medical records contribute to the accuracy of medical staff in making a diagnosis so that they can determine the correct diagnosis code according to the ICD-10 guidelines. A good medical record shows that a doctor or other medical staff has carried out their duties by the demands of their profession as stated in the Medical Practice Law No.29 of 2004. Purposes: To find out there is or not a correlation between the medical information completeness and the accuracy of the diagnosis code for upper respiratory tract infection and hypertension based on the ICD-10 in the medical record documents of outpatients at the Cibening Health Center in 2019. Method: The method used in this study is observational analytic with a cross-sectional study design. The population of this study was outpatient medical records with a diagnosis of upper respiratory tract infection and hypertension at the Cibening Health Center in 2019. The sampling technique used a simple random sampling technique with a sample size of 100. Results: Out of obtained 71 complete medical record (71%) filling in medical records, 64 medical records (64%) were accurate in giving ICD-10 codes, 63 medical records (88.7%) with complete medical information had accurate diagnosis codes in comparison with 8 medical records (11.3%) which were complete but inaccurate diagnosis code. Conclusion: With a p-value of 0.000, there is a significant correlation between the completeness of medical information and the accuracy of the diagnosis code for Upper Respiratory Tract Infection and Hypertension based on ICD-10.

APA, Harvard, Vancouver, ISO, and other styles

41

Wellner, B., M. Huyck, S. Mardis, J. Aberdeen, A. Morgan, L. Peshkin, A. Yeh, J. Hitzeman, and L. Hirschman. "Rapidly Retargetable Approaches to De-identification in Medical Records." Journal of the American Medical Informatics Association 14, no. 5 (September 1, 2007): 564–73. http://dx.doi.org/10.1197/jamia.m2435.

Full text

APA, Harvard, Vancouver, ISO, and other styles

42

Salmasian, Hojjat, Daniel E. Freedberg, and Carol Friedman. "Deriving comorbidities from medical records using natural language processing." Journal of the American Medical Informatics Association 20, e2 (December 2013): e239-e242. http://dx.doi.org/10.1136/amiajnl-2013-001889.

Full text

APA, Harvard, Vancouver, ISO, and other styles

43

Zeng, Xian, Zheng Jia, Zhiqiang He, Weihong Chen, Xudong Lu, Huilong Duan, and Haomin Li. "Measure clinical drug–drug similarity using Electronic Medical Records." International Journal of Medical Informatics 124 (April 2019): 97–103. http://dx.doi.org/10.1016/j.ijmedinf.2019.02.003.

Full text

APA, Harvard, Vancouver, ISO, and other styles

44

Yokoi, H., S. Fujita, K. Takabayashi, and T. Suzuki. "Automatic DPC Code Selection from Electronic Medical Records." Methods of Information in Medicine 47, no. 06 (2008): 541–48. http://dx.doi.org/10.3414/me9128.

Full text

Abstract:

Summary Objectives: We extracted index terms related to diseases recorded in hospital discharge summaries and examined the capability of the vector space model to select a suitable diagnosis with these terms. Methods: By morphological analysis, we extracted index terms and constructed an original dictionary for the discharge summary analysis. We chose 125 different DPC (Japanese DRG system) codes for the diseases, each of which had more than 20 cases. We divided them into two groups. One group consisted of 5927 cases from 2004 fiscal year and was used to generate the document vector space according to the DPC. The other group of 3187 cases was collected to verify the automatic DPC selection by using data from 2005 fiscal year. The top 200 extracted index terms for each disease were used to calculate the weight of each disease. Results: The DPC code obtained by the calculated similarity was compared with the original codes of patients for 125 DPCs of 3187 cases. Eighty percent of the cases matched the diagnosis of the DPC (first six digits) and 56% of the cases completely matched all 14 digits of the DPC. Conclusions: We demonstrated that we could extract suitable terms for each disease and obtain characteristics, such as the diagnosis, from the calculated vectors. This technique can be used to measure the qualification of discharge summaries and to integrate discharge summaries among different facilities. By the text mining technique, we can characterize the contents of electronic discharge summaries and deduce diagnoses with the data.

APA, Harvard, Vancouver, ISO, and other styles

45

van der Lei, J. "Use and Abuse of Computer-Stored Medical Records." Methods of Information in Medicine 30, no. 02 (1991): 79–80. http://dx.doi.org/10.1055/s-0038-1634831.

Full text

APA, Harvard, Vancouver, ISO, and other styles

46

Spyropoulos, B., and G. Papagounos. "The Multifarious Function of Medical Records: Ethical Issues." Methods of Information in Medicine 38, no. 04/05 (1999): 317–20. http://dx.doi.org/10.1055/s-0038-1634408.

Full text

Abstract:

AbstractMedical records comprise history data, physical examination, biosignals, data acquired through in vitro diagnostic tests, images, therapeutic data, and administrative data. Beyond the use of records for therapy, they are also used in research, teaching, the allocation of resources, and for the construction of the patient’s personal history. These functions give rise to a number of important ethical issues. The most important ethical issues are the patient’s autonomy in decisions pertaining to proposed therapeutic interventions, the confidentiality of the information contained in the records, the reliability of the information for research, and questions related to healthcare policy and the distribution of healthcare resources.

APA, Harvard, Vancouver, ISO, and other styles

47

Garrett, L. E., W. E. Hammond, and W. W. Stead. "The Effects of Computerized Medical Records on Provider Efficiency and Quality of Care." Methods of Information in Medicine 25, no. 03 (July 1986): 151–57. http://dx.doi.org/10.1055/s-0038-1635467.

Full text

Abstract:

SummaryTo study the effect of computerized medical records on the efficiency of providers and the quality of care, 245 patient visits were randomly assigned to manual (134 visits) or computerized (111 visits) records during the implementation of a comprehensive medical information system, TMR, in the renal clinic of the Durham VA Medical Center. Data were collected on the time required for the providers to perform their various functions in the clinic. With the exception of prescription writing, the computerized records resulted in significant reductions in the time required for the physicians to obtain data from and enter data into the record (p <0.01). A similar time reduction was noted for the nursing pre-interview (p <0.001) when the computerized records were employed. With the inclusion of the time required for clerical computer data entry, no overall difference in person hours per visit was noted. The clinician’s utilization of the recorded data was significantly better (p <0.001) for the computerized records. Significant reductions in medication errors were also noted (p <0.01).

APA, Harvard, Vancouver, ISO, and other styles

48

Dong, Lorraine. "Taking the long view of medical records preservation and archives." Journal of Documentation 71, no. 2 (March 9, 2015): 387–400. http://dx.doi.org/10.1108/jd-11-2013-0141.

Full text

Abstract:

Purpose – The purpose of this paper is to present an argument for taking the long view of the retention and preservation of inactive medical records. Design/methodology/approach – Using the theoretical framework of Actor-Network Theory, the author examines medical records, and especially mental health records, as actants that participate in the classification and treatment of patients, and in the development of psychiatry and mental hospitals as social institutions. Findings – The varied and profound roles of medical records demonstrate the ability for records to have multiple “lives” that can touch many individuals beyond a single human lifetime. Practical implications – As the current and future custodians of historical medical record collections, information professionals are in a position to be greater advocates for the increased preservation of and mindful access to these materials. Social implications – Medical records have potential to be cultural heritage documents, especially for emergent communities. Originality/value – This paper articulates the ways in which medical records are an embedded part of many societies, and affect the ways in which illness is defined and treated. It thus suggests that while laws regarding the retention and destruction of and access to medical records continue to be deliberated upon around the world, such records can have enduring value as information artifacts.

APA, Harvard, Vancouver, ISO, and other styles

49

Liu, Liping, and Qingxiong Ma. "Emerging e-business technologies for electronic medical records." International Journal of Healthcare Technology and Management 5, no. 3/4/5 (2003): 157. http://dx.doi.org/10.1504/ijhtm.2003.004124.

Full text

APA, Harvard, Vancouver, ISO, and other styles

50

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

Journal articles on the topic 'Medical records Medical records Medical informatics'

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