Journal articles: 'Medical records Medical records Medical records Medical informatics'

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Pourasghar, Faramarz, Hossein Malekafzali, Sabine Koch, and Uno Fors. "Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: An Iranian case study." International Journal of Technology Assessment in Health Care 24, no. 04 (October 2008): 445–51. http://dx.doi.org/10.1017/s0266462308080586.

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Objectives:Information technology is a rapidly expanding branch of science which has affected other sciences. One example of using information technology in medicine is the Electronic Medical Records system. One medical university in Iran decided to introduce such system in its hospital. This study was designed to identify the factors which influence the quality of medical documentation when paper-based records are replaced with electronic records.Methods:A set of 300 electronic medical records was randomly selected and evaluated against eleven checklists in terms of documentation of medical information, availability, accuracy and ease of use. To get the opinion of the care-providers on the electronic medical records system, ten physicians and ten nurses were interviewed by using of semi-structured guidelines. The results were also compared with a prior study with 300 paper-based medical records.Results:The quality of documentation of the medical records was improved in areas where nurses were involved, but those parts which needed physicians' involvement were actually worse. High workloads, shortage of bedside hardware and lack of software features were prominent influential factors in the quality of documentation. The results also indicate that the retrieval of information from the electronic medical records is easier and faster, especially in emergency situations.Conclusions:The electronic medical records system can be a good substitute for the paper-based medical records system. However, according to this study, some factors such as low physician acceptance of the electronic medical record system, lack of administrative mechanisms (for instance supervision, neglecting physicians and/or nurses in the development and implementation phases and also continuous training), availability of hardware as well as lack of specific software features can negatively affect transition from a paper-based system to an electronic system.

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Tran, Thi Tra Mi, and Thi Hong Tran. "Compliance with regulations on recording inpatient obstetric medical records and its influencing factors at Tra Vinh obstetrics and pediatrics hospital in 2020." Journal of Health and Development Studies 05, no. 03 (May 30, 2021): 125–32. http://dx.doi.org/10.38148/jhds.0503skpt21-002.

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Background: Medical records are one of the important contents to ensure the monitoring, management of medical examination and treatment, storing and searching patient information, and scientific research. Objects and research methods: Cross descriptive research design with actual sample size of 255 HSBA. Results: The content of the general information section reached the lowest rate in the content of the administrative section of 83.9%. Other contents in this section have the rate of 90.9% - 99.8%. The average rate of general information is 92.9%. Contents of the medical history section, the proportion of satisfactory contents such as the reason for admission to the hospital (99.6%), the questioning part (96.3%) and the medical examination were quite high (97.8%), content of monitoring at the delivery chamber was only 73.7%. The average percentage of medical records meeting the requirements of the medical record part is 91.9%. Content inside medical records: The average rate is 91.1%. Conclusion: The medical records which have 85% to <100% of corrected items accounts for 98.1%. There should be specific instructions on how to record medical records at Tra Vinh Obstetrics and Pediatrics hospital Keywords: Medical record, completeness, timeliness

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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.

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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.

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Abdel-Monem, Tarik, Mitchel N. Herian, and Nancy Shank. "Electronic Medical Records and Public Perceptions." International Journal of Healthcare Information Systems and Informatics 8, no. 3 (July 2013): 38–57. http://dx.doi.org/10.4018/jhisi.2013070103.

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Public attitudes about electronic medical records (EMRs) have been primarily gauged by one-time opinion polls. The authors investigated the impact of an interactive deliberative polling process on general attitudes towards EMRs and perceptions of governmental roles in the area. An initial online survey was conducted about EMRs among a sample of respondents (n = 138), and then surveyed a sub-sample after they had engaged in a deliberative discussion about EMR issues with peers and policymakers (n = 24). Significant changes in opinions about EMRs and governmental roles were found following the deliberative discussion. Overall support for EMRs increased significantly, although concerns about security and confidentiality remained. This indicates that one way to address concerns about EMRs is to provide opportunities for deliberation with policymakers. The policy and theoretical implications of these findings are briefly discussed within.

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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.

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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.

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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.

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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.

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Yuliartanto, Purnaresa, Adian Fatchur Rochim, and Ike Pertiwi Windasari. "Pengembangan Sistem Informasi Rekam Medis untuk Dinas Kabupaten Grobogan." Jurnal Teknologi dan Sistem Komputer 2, no. 3 (August 31, 2014): 203–8. http://dx.doi.org/10.14710/jtsiskom.2.3.2014.203-208.

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Abstract - Health services include the recording of the patient's medical record . Medical records were used to aid the treatment process. The number of medical records continues to grow proportional to the number of patients. Tens of thousands of sheets of paper used to record medical record requires effort , time and place great . The amount of effort will continue to grow each day. Search one sheet of medical records among a set of storage shelves requires considerable time and risk data is not found. The risk of error in the search and storing will increase every day. The development of technology allows the implementation of technology in the process of record-keeping. Changes in the form of digital medical records will reduce the need of a previous process. Labor, time and place required by the help of information systems will be reduced significantly . Storage process data stored in the cloud will provide more value for the system as a patient's medical records from a health center can be accessed from other health centers. The development of this system will reduce the risk of inappropriate storage and retrieval of medical records. Grobogan Health Department that oversees health center in Grobogan are office that are ready to migrate business processes into the digital age. Development of medical record information system for the health center expected to improve the quality of service of health centers , especially in health care.

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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.

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Gale, Colin, and Katherine Webb. "MAXIMISING ACCESS TO HISTORIC MEDICAL RECORDS." Archives: The Journal of the British Records Association 33, no. 118 (April 2008): 70–84. http://dx.doi.org/10.3828/archives.2008.5.

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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.

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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.

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Wu, Yuju, Huan Zhou, Xiao Ma, Yaojiang Shi, Hao Xue, Chengchao Zhou, Hongmei Yi, Alexis Medina, Jason Li, and Sean Sylvia. "Using standardised patients to assess the quality of medical records: an application and evidence from rural China." BMJ Quality & Safety 29, no. 6 (November 27, 2019): 491–98. http://dx.doi.org/10.1136/bmjqs-2019-009890.

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BackgroundMedical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries.ObjectiveTo provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.MethodsA sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.ResultsMedical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider’s income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β −0.87, 95% CI −1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness.ConclusionDespite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.

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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.

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Qin, Qiuli, Biyuan Jin, and Yanqing Liu. "A Secure Storage and Sharing Scheme of Stroke Electronic Medical Records Based on Consortium Blockchain." BioMed Research International 2021 (February 1, 2021): 1–14. http://dx.doi.org/10.1155/2021/6676171.

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The maintenance and sharing of electronic medical records are one of the essential tasks in the medical treatment combination. Traditional cloud-based electronic medical record storage system is difficult to realize data security sharing. The tamper resistance and traceability of blockchain technology provide the possibility for the sharing of highly sensitive medical data. This paper proposes a safe sharing scheme of stroke electronic medical records based on the consortium blockchain. The scheme adopts the storage method of ciphertext of medical records stored in the cloud and index of medical records stored on the blockchain. The privacy protection mechanism proposed in this paper innovatively combines proxy reencryption and searchable encryption which supports patient pseudoidentity search. The mechanism could achieve controllable sharing of medical records and precise search. According to the organizational characteristics of the stroke medical treatment combination, this paper proposes an improved Practical Byzantine Fault Tolerance mechanism to reach a consensus between consensus nodes. Then, the proposed scheme is analyzed and evaluated from three aspects of medical record integrity, user privacy, and data security. The results show that the scheme can not only ensure the privacy of patient identity information and private key data but also resist the tampering and deletion attacks of internal and external malicious nodes on the medical record data. Therefore, the proposed scheme is conducive to the improvement of the timeliness of stroke treatment and the safe sharing of electronic medical records in stroke medical treatment combination.

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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.

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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.

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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.

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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).

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Szeto, Karen W. H. "New Medical Record System in Queen Elizabeth Hospital, Hong Kong." Health Information Management 24, no. 4 (December 1994): 131–34. http://dx.doi.org/10.1177/183335839402400404.

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During the 1980's, the medical record problems had been identified and it was not until 1991 that Queen Elizabeth Hospital was chosen to be the pilot hospital for the development of a new medical record management system for the Hospital Authority hospitals. The new medical records system was implemented in Queen Elizabeth Hospital in December, 1993. Six month after implementation, a pre-implementation and post-implementation review of the medical record services were conducted to compare the results of the new and old system. The results showed that there were significant improvements in the record retrieval and record integrity in the new system. New medical record services such as the delivery of readmission records to the ward, filing of medical records forms in pre-defined order and filing of loose sheets in the relevant hospital notes are able to facilitate the efficient, effective and complete access to patient information. The support and cooperation of the hospital staff are crucial to the success of the new system. Continuous review and improvement of the new system is essential in order to obtain the best results

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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.

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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).

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

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