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Journal articles on the topic 'Medical records. Medical Records'

Author: Grafiati

Published: 4 June 2021

Last updated: 1 February 2022

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1

Reddy, BH Srinivas, Dr J. N. Rao Dr.J.N.Rao, and Dr B. V. Subrahmanyam Dr.B.V.Subrahmanyam. "Medical Records –Boon Or Bane." Paripex - Indian Journal Of Research 2, no. 2 (January 15, 2012): 238–39. http://dx.doi.org/10.15373/22501991/feb2013/84.

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2

Glynn, Alan, and OMP Jolobe. "Medical Records and their Recorders." Clinical Medicine 3, no. 6 (November 1, 2003): 592.1–592. http://dx.doi.org/10.7861/clinmedicine.3-6-592.

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3

Carpenter, Iain, Mala Bridgelal Ram, Giles P. Croft, and John G. Williams. "Medical records and record-keeping standards." Clinical Medicine 7, no. 4 (August 1, 2007): 328–31. http://dx.doi.org/10.7861/clinmedicine.7-4-328.

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4

Nilegaonkar, Sujit, and PadmajS Kulkarni. "Medical records." Indian Journal of Medical and Paediatric Oncology 41, no. 1 (2020): 47. http://dx.doi.org/10.4103/ijmpo.ijmpo_49_20.

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5

Cahalane, Seamus, James Deeny, and John O'Connell. "Medical Records." Books Ireland, no. 133 (1989): 115. http://dx.doi.org/10.2307/20626192.

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6

TAN, S. Y. "Medical Records." Family Practice News 41, no. 14 (September 2011): 62–63. http://dx.doi.org/10.1016/s0300-7073(11)70788-5.

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7

Lane, Vic, and Peter Hayward. "Medical records." Lancet 353, no. 9149 (January 1999): 330. http://dx.doi.org/10.1016/s0140-6736(05)74890-x.

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8

Tan, S. Y. "Medical Records." Internal Medicine News 44, no. 12 (July 2011): 68. http://dx.doi.org/10.1016/s1097-8690(11)70632-1.

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9

Michael, Robin. "Paperless Medical Records." Australian Medical Record Journal 19, no. 4 (December 1989): 149–54. http://dx.doi.org/10.1177/183335838901900404.

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Flinders Medical Centre (FMC) in South Australia has a storage problem. The space available for filing existing medical records is full, while the demand for additional storage continues its linear growth. The hospital plans to use this “crisis” as an opportunity to review the entire basis for the management of the medical record and pilot an optical disk system as a precursor to paperless medical records. There are many constraints to this objective, but many advantages if the scheme proves successful. Michael describes the events which precipitated this project and outlines the steps in FMC's planned progression to a paperless record. (AMRJ, 1989, 19(4), 149–154).

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10

Slaughter, Jim. "The Medical Records Professionalsʼ View of the Electronic Medical Record." Journal of Ambulatory Care Management 23, no. 2 (April 2000): 18–26. http://dx.doi.org/10.1097/00004479-200004000-00004.

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11

Ballance, Dennis W., Paul R. Brentson, and Janet Aldrich. "The Electronic Medical Record: Medical Records That Teach Communication Skills." Journal of Veterinary Medical Education 33, no. 1 (March 2006): 81–84. http://dx.doi.org/10.3138/jvme.33.1.81.

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12

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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13

Pagano, Michael P., and David Mair. "Writing Medical Records." Journal of Technical Writing and Communication 16, no. 4 (October 1986): 331–41. http://dx.doi.org/10.2190/wy9t-634e-v2jt-jdvq.

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A study was undertaken both to evaluate how medical students are taught to write patient records and to examine the writing done by doctors. Typical medical records, written by medical doctors, were also evaluated. A single questionnaire was sent to eighty-four medical school professors, twenty law school faculty, and five practicing attorneys. The questionnaire asked how medical records were used and what the legal implications were in authoring a patient record. The medical professionals were also asked how their schools taught medical writing. The questionnaire pointed out that most medical schools teach less than ten hours of medical writing in their curricula and that patient records are not written with an understanding of the various audiences, purposes, and uses for medical documents. Two radiology reports are discussed in terms of their clarity and usefulness for medical and extra-medical readers. The study concludes that medical students should be taught a composing process so that they will understand the audience, purpose, and use for the patient records they write.

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14

Potts, Jerry F. "Electronic medical records." Postgraduate Medicine 101, no. 2 (February 1997): 31–36. http://dx.doi.org/10.3810/pgm.1997.02.154.

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15

Marks, Eric S. "Poor Medical Records." Annals of Internal Medicine 110, no. 12 (June 15, 1989): 1037. http://dx.doi.org/10.7326/0003-4819-110-12-1037_1.

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16

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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17

Callan, Laura, and Nancy Chen. "Electronic Medical Records." University of Western Ontario Medical Journal 82, no. 2 (July 30, 2014): 31–32. http://dx.doi.org/10.5206/uwomj.v82i2.4605.

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18

Malakar, Rajib. "Electronic medical records." Indian Journal of Dermatology 51, no. 2 (2006): 140. http://dx.doi.org/10.4103/0019-5154.26940.

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19

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

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20

Claeys, Patricia M. "Electronic Medical Records." Gastroenterology Nursing 30, no. 2 (March 2007): 144. http://dx.doi.org/10.1097/01.sga.0000267956.75759.ce.

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21

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

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22

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

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23

Rutberg, Martin P. "MEDICAL RECORDS CONFIDENTIALITY." Neurologic Clinics 17, no. 2 (May 1999): 307–13. http://dx.doi.org/10.1016/s0733-8619(05)70133-x.

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24

Hochheiser, Harry, and Ben Shneiderman. "Electronic medical records." Interactions 18, no. 6 (November 2011): 48–49. http://dx.doi.org/10.1145/2029976.2029989.

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25

Smith, James F. "Occupational Medical Records." AAOHN Journal 42, no. 1 (January 1994): 18–22. http://dx.doi.org/10.1177/216507999404200105.

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26

Avitzur, Orly. "ELECTRONIC MEDICAL RECORDS." Neurology Today 2, no. 5 (May 2002): 30–31. http://dx.doi.org/10.1097/00132985-200205000-00011.

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27

Whitlock, Ginger H. "Electronic medical records." Journal of Ambulatory Care Management 15, no. 3 (July 1992): 76–80. http://dx.doi.org/10.1097/00004479-199207000-00008.

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28

Frampton, Susan B., Sheryl Horowitz, and Barbara J. Stumpo. "Open Medical Records." AJN, American Journal of Nursing 109, no. 8 (August 2009): 59–63. http://dx.doi.org/10.1097/01.naj.0000358504.52667.71.

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29

Steward, Melissa. "Electronic Medical Records." Journal of Legal Medicine 26, no. 4 (December 2005): 491–506. http://dx.doi.org/10.1080/01947640500364762.

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30

Smith, Mike. "Protecting Medical Records." ITNOW 60, no. 4 (2018): 14–15. http://dx.doi.org/10.1093/itnow/bwy089.

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31

McCOY, MICHAEL JAMES. "Electronic Medical Records." Clinical Obstetrics and Gynecology 55, no. 3 (September 2012): 605–12. http://dx.doi.org/10.1097/grf.0b013e31825ca574.

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32

Shrader, J. A. "Computerized medical records." Academic Medicine 63, no. 12 (December 1988): 928–9. http://dx.doi.org/10.1097/00001888-198812000-00011.

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33

Double, D. B. "Editing medical records." BMJ 303, no. 6805 (September 28, 1991): 787. http://dx.doi.org/10.1136/bmj.303.6805.787-b.

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34

Charney, Pamela. "Electronic Medical Records." Nutrition in Clinical Practice 27, no. 6 (October 18, 2012): 715–17. http://dx.doi.org/10.1177/0884533612464784.

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35

Kolpan, Kenneth I. "Disclosing medical records." Journal of Head Trauma Rehabilitation 4, no. 3 (September 1989): 95–96. http://dx.doi.org/10.1097/00001199-198909000-00016.

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36

Tevaarwerk, G. J. M. "Electronic medical records." Canadian Medical Association Journal 178, no. 10 (May 6, 2008): 1323. http://dx.doi.org/10.1503/cmaj.1080032.

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37

Greiver, M. "Electronic medical records." Canadian Medical Association Journal 178, no. 10 (May 6, 2008): 1323–24. http://dx.doi.org/10.1503/cmaj.1080033.

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38

Viner, G., and A. Parush. "Electronic medical records." Canadian Medical Association Journal 179, no. 1 (June 12, 2008): 54. http://dx.doi.org/10.1503/cmaj.1080036.

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39

Heinlein, Edwin B. "Medical records security." Computers & Security 15, no. 2 (January 1996): 100–102. http://dx.doi.org/10.1016/0167-4048(96)89322-9.

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40

Anggraeni, Devina, and Muhammad Ikhsan. "The Role of Electronic Medical Records as Evidence in Medical Disputes in Hospitals." SOEPRA 5, no. 2 (April 2, 2020): 311. http://dx.doi.org/10.24167/shk.v5i2.2428.

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Medical Record is a file that contains records and other documents such as patient identification, examination, the treatment that has been given to the patient. Based on the Minister of Health No. 269/MENKES/PER /III / 2008 concerning the medical record that there are two types of medical records that conventional medical records and electronic medical records. With the absence of a strong legal basis related to the setting of electronic medical records, but in reality, many hospitals are using electronic medical records which raised the question, how the role of electronic medical records as evidence in the medical dispute that occurred in the hospital ?. This study uses Descriptio with the normative juridical approach. The data used is qualitative. This is done to get an overview of the roles of electronic medical records as evidence in the medical dispute in the hospital. Electronic medical records in the case of medical dispute resolution in the hospital can not be made as evidence in the medical case settlement, because the regulations related to the use of electronic medical records alone do not yet have a clear legal basis.

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41

Houston, Michael. "The Psychiatric Medical Record, HIPAA, and the Use of Electronic Medical Records." Child and Adolescent Psychiatric Clinics of North America 19, no. 1 (January 2010): 107–14. http://dx.doi.org/10.1016/j.chc.2009.08.011.

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42

Gochi, Akira. "Electronic medical records and medical insurance." Okayama Igakkai Zasshi (Journal of Okayama Medical Association) 124, no. 3 (2012): 223–29. http://dx.doi.org/10.4044/joma.124.223.

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43

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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44

Shaw, Jane. "Keeping the Record: Medical Records in a Small Hospital." Tropical Doctor 28, no. 3 (July 1998): 131–33. http://dx.doi.org/10.1177/004947559802800303.

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45

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

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

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46

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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47

Berlin, L. "Alteration of medical records." American Journal of Roentgenology 168, no. 6 (June 1997): 1405–8. http://dx.doi.org/10.2214/ajr.168.6.9168697.

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48

Arya, Vibhuti. "Medical records extreme makeover." Pharmacy Today 19, no. 3 (March 2013): 32. http://dx.doi.org/10.1016/s1042-0991(15)31486-9.

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49

Hoffmann, Leah. "Implementing electronic medical records." Communications of the ACM 52, no. 11 (November 2009): 18–20. http://dx.doi.org/10.1145/1592761.1592770.

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50

Dubik, M. "Music and Medical Records." AAP Grand Rounds 33, no. 1 (January 1, 2015): 12. http://dx.doi.org/10.1542/gr.33-1-12.

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