To see the other types of publications on this topic, follow the link: Medical records Medical writing.
Journal articles on the topic 'Medical records Medical writing'
Create a spot-on reference in APA, MLA, Chicago, Harvard, and other styles
Consult the top 50 journal articles for your research on the topic 'Medical records Medical writing.'
Next to every source in the list of references, there is an 'Add to bibliography' button. Press on it, and we will generate automatically the bibliographic reference to the chosen work in the citation style you need: APA, MLA, Harvard, Chicago, Vancouver, etc.
You can also download the full text of the academic publication as pdf and read online its abstract whenever available in the metadata.
Browse journal articles on a wide variety of disciplines and organise your bibliography correctly.
1
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.
Full textAbstract:
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.
2
McCalman, Janet. "Writing the Women's-Hospital History with Medical Records." Health and History 1, no. 2/3 (1999): 132. http://dx.doi.org/10.2307/40111339.
Full text
3
Ou, Hui, Xiaoyan Tan, and Ling Li. "Case Analysis on Writing Standards of Medical Records." Chinese Medical Record English Edition 1, no. 8 (August 2013): 347–49. http://dx.doi.org/10.3109/23256176.2013.842719.
Full text
4
Nurhayati, Yunita Wisda Tumarta Arif, and Ahmad Yusron Yunizar. "Rancang Bangun Website Rekam Medis Elektronik di Fasilitas Pelayanan Kesehatan Praktik Dokter." Infokes: Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan 10, no. 2 (September 28, 2020): 49–54. http://dx.doi.org/10.47701/infokes.v10i2.1033.
Full textAbstract:
Electronic medical records record electronic medical records which contain personal data, demographic data, social data, clinical / medical data. Processing of medical record documents at doctor's practice health facilities is still done manually, starting from patient registration, writing examination history, and storing medical record documents. One of the efforts to overcome these obstacles is by building an Electronic Medical Record website. The website development method uses the development life cycle system. Medical records are processed from input patient data, diagnostic data, action data, drug data, officer data, registration data, examination data. Then the data is processed to produce reports, including patient data, and examination data. The electronic medical record website used can simplify the processing of medical record data.
5
Ratnawati, Ratnawati. "Analysis The Level of Compliance of Hospital Human Resources in Writing The Status of Inpatient Medical Record Dr Sayidiman Hospital and The Influences Factors." Journal for Quality in Public Health 3, no. 2 (May 12, 2020): 423–33. http://dx.doi.org/10.30994/jqph.v3i2.92.
Full textAbstract:
The quality of medical records in hospitals also determines the quality of service, completeness of writing Medical Records documents correctly and correctly is very important. The purpose of this study was to analyze the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr. Sayidiman Magetan Regional Hospital and the factors that influence it. The design of this study was an observational quantitative study with a cross section approach with the focus of the research directed to be analyzing the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr Sayidiman Magetan Regional Hospital and the factors that influenced it with a sample of 192 respondents taken with the Simple Random Sampling technique. The findings found that most of the respondents have high motivation that is 144 respondents (75%). Most of the respondents care to write in the medical record that is 160 respondents (83.3%). Most of the respondents have a high appreciation of 136 respondents (70.8%). Most of the respondents did not comply doing medical record writing of 107 respondents (55.7%). Based on the Linear Regression analysis the motivation variable on compliance p-value 0.015 <0.05, the variable concern for compliance p-value 0.025 <0.05 then H0 is rejected so there is the influence of motivation and concern for compliance with medical record writing by health professionals in Regional General Hospital Dr. Sayidiman Magetan. Linear regression variable rewards for compliance shows that the p-value of 0.665> 0.05 then H0 is accepted so it is concluded that there is no effect of rewards on compliance with writing medical records by health professionals at the Dr Sayidiman Magetan Regional General Hospital. It is expected that respondents can comply to fill out medical records so that the delivery of care to passion can be well integrated
6
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 textAbstract:
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.
7
Berutu, Chris Anggi Natalia, Yanti Agustina, and Sonya Airini Batubara. "KEKUATAN HUKUM PEMBUKTIAN REKAM MEDIS KONVESIONAL DAN ELEKTRONIK BERDASARKAN HUKUM POSITIF INDONESIA." Jurnal Hukum Samudra Keadilan 15, no. 2 (December 21, 2020): 305–17. http://dx.doi.org/10.33059/jhsk.v15i2.2686.
Full textAbstract:
Medical records are files containing patient records, which are made chronological time. There are two types of medical records and in general have been regulated in Permenkes Number 269 / MENKES / PER / III / 2008 concerning Medical Records, namely conventional medical records and electronic medical records. One of the benefits of medical records is as evidence in the law enforcement process. This type of research is normative juridical research and is analytical descriptive in nature. The data source used in this research is secondary data, which is obtained from books, journals, expert opinions and others. The data collection technique used is to collect data in this study through documentation studies in the form of data collection from literature or scientific writing in accordance with the object under study. Data analysis is data obtained and then analyzed qualitatively. From the study it is concluded that the difference in the strength of evidence lies in the non-fulfillment of the requirements of electronic medical records as written / letter evidence, in accordance with the Criminal Code Book 4, Concerning Evidence and Expiration, Second Chapter on Evidence by Writing and KUHAP Article 184 paragraph (1) letter c and d, as well as Articles 187 and 188 paragraph (2) letter b. This means that conventional medical records can be used as original written evidence, whereas electronic medical records cannot. The cause of the difference is because both the Criminal Code and the Criminal Procedure Code, the power of written evidence, is only in writing, in the form of original letters and / or authentic deeds. The data used are (1) primary data in the form of statutory regulations, results of interviews with hospitals and courts, (2) secondary data through literature studies of various laws and regulations and books / journals to obtain expert opinion. The results of this research are expected to be published through (1) scientific articles in Accredited National Journals and (2) teaching materials in Law courses at the Faculty of Law at Prima Indonesia University.
8
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 textAbstract:
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).
9
Gosanti, Ayunda Zilul, and Ernawaty Ernawaty. "Analisis Kelengkapan Penulisan Soap, KIE, dan ICD X pada Rekam Medis di Poli Umum dan KIA-KB Puskesmas X Surabaya." Jurnal Administrasi Kesehatan Indonesia 5, no. 2 (January 2, 2018): 139. http://dx.doi.org/10.20473/jaki.v5i2.2017.139-144.
Full textAbstract:
Based on the standart that Public Health Center “X” completeness of SOAP, KIE, and ICD X must be 100%. The aim of research was to analyze how the completeness of writing SOAP, KIE, and ICD X inGeneral Poly and Health of Mother and Child Family Planning Public Health Center “X”. This study was descriptive research with 500 medical records that consist of 260 for January and 240 for February as sample and they taken by random sampling. The result showed that completeness of SOAP, KIE, and ICD X on January in General Poly were 48% and decrease on February became 45,8%.While Health Mother and Child Family Planning Poly showed that completeness on January were 97,8% and increase on February became 98,6%. The incompleteness of medical records can be influenced by several factors is compliance the health workers who responsible in filling the medical records and they have multi job in Public Health Center “X” also the patient was increase. To minimize the incompleteness of SOAP, KIE, and ICD X, medical staff needs to expose by socialization of medical record to remember their responsibilty of their job description.Keywords : Completeness, medical record, Public Health Center
10
Fananca, Muhammad Andy, Aliyadi Aliyadi, and Dwiyono Ariyadi. "RANCANG BANGUN APLIKASI REKAM MEDIS BAGI PASIEN UNIT KESEHATAN KAMPUS BERBASIS WEB (Studi Kasus: Universitas Muhammadiyah Ponorogo)." KOMPUTEK 4, no. 2 (October 28, 2020): 73. http://dx.doi.org/10.24269/jkt.v4i2.536.
Full textAbstract:
To improve health care and processing data for medical records at the Muhammadiyah Ponorogo University campus health unit, a modern medical record information system is needed. The current medical record-recording process in the Muhammadiyah University campus medical unit of Ponorogo is still done by hand, which is by writing in a book and a patient's treatment card. This is running less optimal because an official has to retrieve and retrieve the data that will be needed in a patient's books and treatment cards, so it takes little time and space. The aim of this study is to develop an existing medical record system, becoming a web-based modern medical record system for patients to record clearly and more efficiently. The study begins with observation, study literature, and then follows the design method using the waterfall model, the context diagram design, the flow diagram (DFD), entity relathionship diagram (erd), system interface design and application testing. With the design of this application for medical records, it is hoped to be beneficial and can improve health care at UKK Muhammadiyah University Ponorogo. The design of this medical record application is still in short supply, and few improvements and innovations that the age has developed need to be made.
11
Xu, Gujun, Jie Liu, and Yanhui Wang. "Discussion on Medical Record Writing and Medical Dispute Prevention in the Traumatology Department." Chinese Medical Record English Edition 2, no. 4 (June 2014): 182–85. http://dx.doi.org/10.3109/23256176.2014.927166.
Full text
12
Nierenberg, Chet, Christopher Brigham, Lorne K. Direnfeld, and Clarissa Burket. "Standards for Independent Medical Examinations." Guides Newsletter 10, no. 6 (November 1, 2005): 1–9. http://dx.doi.org/10.1001/amaguidesnewsletters.2005.novdec01.
Full textAbstract:
Abstract An independent medical evaluation (IME) may be more comprehensive and may contain more elements than an impairment evaluation, but to date no standards have defined a high-quality IME. The authors, a group of experienced IME physicians, note the variability of requirements in individual IME cases, but they have identified standards that generally apply to IME reports and include the following: definition of IME and key concepts; examiner qualifications; methodology and procedures; the physical examination; suggested generalized report format; and quality assurance. An IMR is a specialized examination and report, ideally performed by a medical physician with special training and experience in IMEs; an IME is not a medical consultation and report but rather an opportunity to determine diagnosis and document the clinical course over time. Examiners should be qualified by experience and qualifications and ideally should have a special credential from an independent medical examiners association and must be knowledgeable about IME report writing. A section of the article describes the structure of the IME report, which may vary from examiner to examiner but should include careful attention to descriptive data, history, record review, oral history, physical examination, records of other objective data, and an opinion section (with diagnoses, discussion, past medical treatment, maximum medical improvement, future medical treatment, causation and apportionment, disability/functional status, prognosis, answers to specific questions, and references.
13
Fu, Qiang, Ping Wang, and Li Zhao. "Feasibility and Countermeasures of Simplifying Hospital Medical Record Writing." Chinese Medical Record English Edition 1, no. 8 (August 2013): 350–53. http://dx.doi.org/10.3109/23256176.2013.842723.
Full text
14
Liu, Caihua, Yongjun Xia, and Jie Qiu. "Influence of Medical Record Home Page Writing on DRGs." Chinese Medical Record English Edition 1, no. 12 (December 2013): 529–32. http://dx.doi.org/10.3109/23256176.2013.882568.
Full text
15
., Yastori. "Analysis of obstetric code accuracy at hospital X in Padang 2018 based on international classification of diseases the 10th revision." International Journal Of Community Medicine And Public Health 7, no. 4 (March 26, 2020): 1250. http://dx.doi.org/10.18203/2394-6040.ijcmph20201428.
Full textAbstract:
Background: Coding is one of the competencies of the health information recorder which has a very important role in supporting the improvement of the quality of health services in accordance with the republic of Indonesia decree No. 377/Menkes/SK/III/2007 regarding the professional standards of medical record and health information, medical recorders must be able to establish codes for diagnosis of disease and medical treatment appropriately. The accuracy of coding is related to financing claims, especially for hospitals that work with health service providers such as health insurance. The purpose of this study is to analyze the accuracy of coding based on international classification of diseases the 10th revision (ICD-10).Methods: Research using descriptive methods with a qualitative approach. The data collection technique used is the observation method that is direct observation of the medical record file. 56 medical records were randomly selected and recoded blindly (as gold standard). Processing statistical data using pivot tables and for coding analysis using ICD-10.Results: Accurate diagnosis code based on the ICD-10 is 14 (25%) and an inaccurate 42 (75%) of 56 diagnoses in the medical record file. The most inaccurate code found is the fourth character with 22 codes.Conclusions: The inaccuracy of coding at hospital X in Padang was caused among others by the doctor's writing that was not clearly read, errors in the selection in sub categories and in the selection of the character code. In addition, people who work in the medical records section are generally not from a medical record background.
16
Klar, R. "Selected Impressions on the Beginning of the Electronic Medical Record and Patient Information." Methods of Information in Medicine 43, no. 05 (2004): 537–42. http://dx.doi.org/10.1055/s-0038-1633913.
Full textAbstract:
Summary Objectives: To present an overview of early European and American work on Electronic Medical Records and patient information. Method: The invited lectures of “pioneers of electronic patient information” given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed. Results: The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first com-puterized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency. Conclusions: Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.
17
Zhu, Daqiao, Wenjun Zhang, Lijiang Yong, and Shaoyong Huang. "Analysis of the First Page of 2,236 Medical Records with Writing Defects and Relevant Countermeasures." Chinese Medical Record English Edition 2, no. 5 (May 2014): 195–98. http://dx.doi.org/10.3109/23256176.2014.932073.
Full text
18
Nandhra, Harpal, Graham Murray, Nigel Hymas, and Neil Hunt. "Medical records: Doctors' and patients' experiences of copying letters to patients." Psychiatric Bulletin 28, no. 2 (February 2004): 40–42. http://dx.doi.org/10.1192/pb.28.2.40.
Full textAbstract:
Aims and MethodWe conducted a pilot study to determine patients' views on receiving a copy of the assessment letter sent to their general practitioner and to determine how psychiatrists' letter writing practice would be altered in the knowledge that patients would receive copies of such letters. Seventy-six consecutive new outpatients received copies of the initial assessment letter sent to general practitioners. Patients were asked to complete a short questionnaire on how the practice affected them. For each letter, psychiatrists were asked to provide details of anything of importance that had been omitted from the letter that in their normal practice they would have included.ResultsThere was a broad range of responses on how patients felt about the letters. Only two patients found the letters unhelpful, and 83% expressed a positive desire to continue receiving letters, even though initially 18% found the letter distressing. For 56 out of 76 patients, psychiatrists stated that they composed and sent out the letter to the GP in accordance with their usual practice and copied the letter to the patient in an unaltered form. For 17 patients, the psychiatrist stated that some information he/she would usually have included in the GP letter was omitted in the copy the patient received. In a further 3 cases, the psychiatrist sent no letter to the patient.Clinical ImplicationsPatients found it helpful to receive copies of their assessment letters. Psychiatrists might require training and reassurance about this policy before implementation.
19
Banagozar Mohammadi, Ali, and Maryam Vahabzadeh. "Medical Confidentiality: Legal and Ethical Challenges in Iran." International Journal of Medical Toxicology and Forensic Medicine 10, no. 1 (March 19, 2020): 27024. http://dx.doi.org/10.32598/ijmtfm.v10i1.27024.
Full textAbstract:
Being a matter of confidentiality, medical "secret" is an issue that physicians are aware of due to nature of their profession. Breach of confidentiality is defined as giving away a patient’s medical records by any means such as writing, telling, implying etc. According to law in Iran, medical confidentiality is one of the principles of medical profession and if anyone breaches it, they can be imprisoned up to one year. It is imperative that medical professionals make every effort to protect their patients’ secrets from being divulged even to their next of kin. Disclosure of patients' secret without their consent also results in public distrust in the healthcare system so that individuals either refuse to see the doctor or give incomplete and inaccurate information in the future, which per se can cause serious health risks.
20
Parvaiz, Muhammad Asad, Ashok Subramanian, and Namita S. Kendall. "The use of abbreviations in medical records in a multidisciplinary world -- an imminent disaster." Communication and Medicine 5, no. 1 (November 27, 2008): 25–34. http://dx.doi.org/10.1558/cam.v5i1.25.
Full textAbstract:
Abbreviations are commonly used in the medical world to save time and space whilst writing in the patients’ medical records. As various specialties have evolved, each has developed a collection of commonly used abbreviations within its practice, which may not be recognizable to those not working within the same field. The purpose of this study was to assess whether we, the multidisciplinary team members, correctly interpret the abbreviations used in the medical records. We analysed one week of orthopaedic surgical medical records for the use of abbreviations and assessed their appreciation by other members of the multidisciplinary team by means of a standardized questionnaire. We found great variability in the understanding of these abbreviations by different groups of health care professionals. As expected, the orthopaedic surgeons produced significantly more right answers when compared to the other groups, but even they could correctly interpret just over half (57.24 per cent) of the abbreviations. There were many misinterpretations of the abbreviations across the specialties posing imminent clinical risk. Whilst abbreviations may indeed save time, the observed inter-group variation in correct interpretation of these abbreviations is unacceptable. We recommend that the abbreviations have no place in the multidisciplinary world and their continued use will only lead to eventual clinical error.
21
Patanwala, Asad E. "A practical guide to conducting and writing medical record review studies." American Journal of Health-System Pharmacy 74, no. 22 (November 15, 2017): 1853–64. http://dx.doi.org/10.2146/ajhp170183.
Full text
22
Hoble, M. Ujair. "Health Monitor System." International Journal for Research in Applied Science and Engineering Technology 9, no. VIII (August 10, 2021): 103–6. http://dx.doi.org/10.22214/ijraset.2021.37278.
Full textAbstract:
Health is a crucial part of human lives. Nowadays, healthcare is becoming vital each day, as there are lots of diseases that emerge around us. Technology is transforming the medical sector by massively impacting almost all practices and processes of medical professionals. Despite this, many of the people and medical staff still dealing with paper-based medical records and prescriptions while conducting treatment. When a patient wants to appoint any hospital or clinic, to carry previous medical reports or past prescriptions is becoming essential for them. It is necessary because the doctor gets an idea about the patient’s health status by referring to their previous medical histories, helping for better treatments and medications. However, patients cannot maintain every medical documentary for years. Conventionally, the doctor asks patients about their previous diseases, prescription, or medicine details orally, nevertheless it becomes difficult to get exact information from the patient. Sometimes, it becomes more important for the doctor to know about the medical history of a person so that they can provide suitable treatment with better clarity of that person’s health. Focussing on this, a smart medical assistant system is designed where doctors can record all prescriptions, treatment, or medical details of the patient on software instead of writing on a paper. All these records are stored in the central cloud and made visible to doctors as well as patients. Each patient has assigned a unique authentication card for maintaining the privacy of their medical history account. Doctors can access and update a patient’s medical history anytime and anywhere by logging into their account through a smartcard swipe. The system can avoid overdue to treatment decisions. Likewise, the system helps to keep transparency about medicines and treatment.
23
Gîfu, Daniela, Diana Trandabăț, Kevin Cohen, and Jingbo Xia. "Special Issue on the Curative Power of Medical Data." Data 4, no. 2 (June 14, 2019): 85. http://dx.doi.org/10.3390/data4020085.
Full textAbstract:
With the massive amounts of medical data made available online, language technologies have proven to be indispensable in processing biomedical and molecular biology literature, health data or patient records. With huge amount of reports, evaluating their impact has long ceased to be a trivial task. Linking the contents of these documents to each other, as well as to specialized ontologies, could enable access to and the discovery of structured clinical information and could foster a major leap in natural language processing and in health research. The aim of this Special Issue, “Curative Power of Medical Data” in Data, is to gather innovative approaches for the exploitation of biomedical data using semantic web technologies and linked data by developing a community involvement in biomedical research. This Special Issue contains four surveys, which include a wide range of topics, from the analysis of biomedical articles writing style, to automatically generating tests from medical references, constructing a Gold standard biomedical corpus or the visualization of biomedical data.
24
Ichikawa, Hiroo, Shinichi Koyama, Hideki Ohno, Kenji Ishihara, Kiyomi Nagumo, and Mitsuru Kawamura. "Writing Errors and Anosognosia in Amyotrophic Lateral Sclerosis with Dementia." Behavioural Neurology 19, no. 3 (2008): 107–16. http://dx.doi.org/10.1155/2008/814846.
Full textAbstract:
Amyotrophic lateral sclerosis (ALS) with dementia (ALS-D) is known to exhibit characteristics of frontotemporal dementia. However, in clinical situations, it is often difficult to evaluate their cognitive functions because of impaired voluntary speech and physical disabilities. In order to identify characteristic and diagnostic cognitive symptoms of relatively advanced ALS-D patients, we retrospectively reviewed the clinical features of seven cases of clinically definitive ALS who had dementia, impaired voluntary speech, and physical disability. Their medical records showed that six out of seven patients made writing errors, and all of the patients demonstrated anosognosia. The writing errors consisted of paragraphia such as substitution, omission, or syntactic errors with individual differences in error types. Dissociation between kana and kanji were also observed. Anosognosia was evaluated by a self-rating scale with which the patients and the medical staff evaluated the patient's physical ability; the results indicated a large discrepancy between the evaluation by the patients and the medical staff. We emphasize that aphasic writing errors have been underestimated, particularly in ALS-D patients with impaired voluntary speech. We also reported that anosognosia was the most important and quantifiable symptom in ALS-D. The relationship between writing errors and anosognosia should be investigated further.
25
Al Solami, N. "Auditing of discharge summaries Contet at Al Amal medical complex." European Psychiatry 33, S1 (March 2016): S563. http://dx.doi.org/10.1016/j.eurpsy.2016.01.2086.
Full textAbstract:
Introduction and aimsPatient's records are the most important clinical assets and tools which are required in consultations. Patient records also support the accurate continuity of care when patients return to other health providers.ObjectiveUnderstand the extent of Discharge Summaries, which conform to the set best practise guidelines on the Mental Health Service.MethodA cross-section retrospective study on Discharge Summary contents was conducted at Al Amal Medical Complex. Chart review of randomly selected patient files (200 of a total 495), of Discharge Summaries for Psychiatric Patients in 2014 was performed. The data was statistically analysed using descriptive statistics taking into account proportions and frequencies. Pearson chi square and Fisher's test methodologies were used.ResultThis study found of the 200 randomly selected Discharge Summaries that documented data of mental health examination 94% (n = 188), data of discharge date 100% (n = 200) while data of social investigation and family work up 82% (n = 164). The above three categories were the only categories to conform to standard discharge guidelines. The other thirteen items studies were found not conforming to the defined standard guidelines.Conclusion and recommendationThere is an active challenge for clinicians to introduce good clinical practice in Mental Health. Standard guidelines must be followed by clinician's in order to reduce potential areas of concern and achieve a good clinical practise. Regular recurring audits are highly needed& recommended to ensure the alignment with standard guidelines for the writing of Discharge Summaries.Disclosure of interestThe author has not supplied his/her declaration of competing interest.
26
Ngonadi, Ifeoma V. "Implementing Internet of Things in a Remote Patient Medical Monitoring System." International Journal of Emerging Research in Management and Technology 6, no. 8 (June 25, 2018): 159. http://dx.doi.org/10.23956/ijermt.v6i8.132.
Full textAbstract:
The Internet of Things (IoT) is a system of interrelated computing devices, mechanical and digital machines, objects, animals or people that are provided with unique identifiers and the ability to transfer data over a network without requiring human-to-human or human-to-computer interaction. Remote patient monitoring enables the monitoring of patients’ vital signs outside the conventional clinical settings which may increase access to care and decrease healthcare delivery costs. This paper focuses on implementing internet of things in a remote patient medical monitoring system. This was achieved by writing two computer applications in java in which one simulates a mobile phone called the Intelligent Personal Digital Assistant (IPDA) which uses a data structure that includes age, smoking habits and alcohol intake to simulate readings for blood pressure, pulse rate and mean arterial pressure continuously every twenty five which it sends to the server. The second java application protects the patients’ medical records as they travel through the networks by employing a symmetric key encryption algorithm which encrypts the patients’ medical records as they are generated and can only be decrypted in the server only by authorized personnel. The result of this research work is the implementation of internet of things in a remote patient medical monitoring system where patients’ vital signs are generated and transferred to the server continuously without human intervention.
27
Wu, Liangxiang. "Study on Quality Control of Time Limit in Electronic Medical Record Writing." Chinese Medical Record English Edition 1, no. 6 (June 2013): 224–26. http://dx.doi.org/10.3109/23256176.2013.825987.
Full text
28
Hu, Xiaoxing, and Hui Li. "Medical Record Writing of Common Malignant Tumor Diseases in Thoracic Surgery Department." Chinese Medical Record English Edition 1, no. 9 (September 2013): 400–402. http://dx.doi.org/10.3109/23256176.2013.857490.
Full text
29
Schiegg, Markus, and Deborah Thorpe. "Historical Analyses of Disordered Handwriting." Written Communication 34, no. 1 (December 21, 2016): 30–53. http://dx.doi.org/10.1177/0741088316681988.
Full textAbstract:
Handwritten texts carry significant information, extending beyond the meaning of their words. Modern neurology, for example, benefits from the interpretation of the graphic features of writing and drawing for the diagnosis and monitoring of diseases and disorders. This article examines how handwriting analysis can be used, and has been used historically, as a methodological tool for the assessment of medical conditions and how this enhances our understanding of historical contexts of writing. We analyze handwritten material, writing tests and letters, from patients in an early 20th-century psychiatric hospital in southern Germany (Irsee/Kaufbeuren). In this institution, early psychiatrists assessed handwriting features, providing us novel insights into the earliest practices of psychiatric handwriting analysis, which can be connected to Berkenkotter’s research on medical admission records. We finally consider the degree to which historical handwriting bears semiotic potential to explain the psychological state and personality of a writer, and how future research in written communication should approach these sources.
30
Manian, Farrin A. "The Case for Writing Critical Thinking Reports as a Teaching Strategy on Today’s Hospital Wards." Journal of Medical Education and Curricular Development 7 (January 2020): 238212052094887. http://dx.doi.org/10.1177/2382120520948879.
Full textAbstract:
I review some of the challenges in teaching medical students and housestaff on today’s hospital medicine wards, including increasingly limited time for dedicated teaching. Tapping into the extensive literature of “writing to learn” or “writing-across-the curriculum” in non-medical educational settings ranging from elementary school to college classes, I urge consideration of writing concise critical thinking reports (CTRs) by medical students and housestaff in response to questions raised during patient rounds as a means of enhancing their ward-based learning experience. Several potential reasons for writing CTRs are offered: (1) Nurtures curiosity; (2) Demands self-directed search for and encoding of new knowledge; (3) Emphasizes metacognition and conceptualization crucial to meaningful learning; (4) Provides opportunity for learners to teach and share newly-assimilated material with a broader web-based audience; (5) Encourages the concept of narrow but more in-depth learning related to a specific clinically relevant subject matter; (6) Nudges learners toward clear and succinct writing as an important general skill to develop in their everyday professional activities, including electronic medical record documentation; and (7) Reduces work-related burnout. Barriers to writing CTRs, including lack of general appreciation for explanatory writing as a potential teaching strategy in medical education and allowing sufficient time for medical students and housestaff to engage in this activity among other competing demands, are discussed. Writing CTRs is a potentially powerful pedagogical tool in ward-based learning that deserves consideration and formal evaluation by properly designed studies.
31
Babiarczyk, Beata, and Danuta Sternal. "Report on the first year of applying initial assessment of nutritional status in hospital inpatients." Polish Journal of Public Health 125, no. 4 (December 1, 2015): 211–14. http://dx.doi.org/10.1515/pjph-2015-0057.
Full textAbstract:
Abstract Introduction. Since 2012, Polish hospitals are recommended to implement the assessment of the nutritional status and appoint nutrition support teams. Aim. To evaluate the application of initial assessment of inpatients’ nutritional status in the first year of its implementation in clinical practice. Material and methods. A retrospective analysis of medical documentation of patients admitted to hospital in the year 2012 was conducted. The research sample included one in ten medical records. Results. A total of 433 medical records was analyzed. In 5.3% medical records a lack of duly completed Subjective Global Assessment questionnaires was revealed. In 81.8% cases a calculated Body Mass Index (BMI) was not found. No instances of renewed calculation of BMI were recorded. In 49.7% cases no information on diet recommended to the inpatient was found. With the exception of the internal medicine ward, in 87% of the cases the diets were not recommended in writing by a physician or included in the medical orders documentation. The inpatients classified as undernourished were usually recommended a diet containing 2000 kcal + additional 300 kcal as second breakfast and afternoon snack. Information on cooperation with the nutrition support team and on inpatient’s nutrition was not included in the nursing documentation. Conclusions. During the first year when the obligatory patient nutritional status assessment was introduced in Polish hospitals, the awareness of its significance, nutritional therapy planning and monitoring of the results were insufficient. The assessment of nutritional status seems to be another dead letter in patient medical documentation.
32
Jaenudin, Jejen, Abdul Qodir Jaelani, and Ade Hendri Hendrawan. "Rancang Bangun Sistem Administrasi Rekam Medis Berbasis Web Pada Klinik Asysyifaa." KREA-TIF 5, no. 2 (March 2, 2017): 66. http://dx.doi.org/10.32832/kreatif.v5i2.2027.
Full textAbstract:
<h1 align="center"><strong>Abstrak</strong></h1><p>Klinik adalah fasilitas pelayanan kesehatan tingkat dasar yang wajib menyelenggarakan rekam medis.Kegiatan administrasi rekam medis yang ada di Klinik Asysyifaa Leuwiliang masih dalam bentuk tulisan pada lembaran kertas, aplikasi ini dibangun untuk mengoptimalkan kinerja klinik dalam hal pengadministrasian data rekam medis yang cepat, tepat, dan akurat. Proses pembuatan aplikasi dimulai dengan analisis kebutuhan sistem, pembuatan desain database, desain sistem, desain user interface, pembangunan sistem, dan pengujian sistem. Metode perancangan sistem yang digunakan yaitu OOAD dengan tools UML. Hasil dari penelitian ini meliputi: proses bisnis lama, proses bisnis baru, diagram konteks, pelaku sistem, list use case, use case diagram, activity diagram, sequence diagram, deployment diagram, dan class diagram. Berdasarkan hasil penelitian disimpulkan bahwa aplikasi yang dibuat melakukan kegiatan login, pendaftaran pasien baru, pasien lama, menyimpan data rekam medis dan menampilkan riwayat rekam medis pasien secara realtime ketika dokter melakukan pemeriksaan, sehingga mampu menggantikan penggunaan rekam medis kertas dan memangkas waktu pelayanan pasien.</p><p align="center"><strong><em>Abstract </em></strong></p><p><em>Clinics are basic health care facilities that are required to conduct medical records. Medical record administration activities at the Asysyifaa Leuwiliang Clinic are still in writing on sheets of paper, this application was built to optimize clinic performance in administering medical records data that is fast, precise, and accurate. The process of making applications starts with system requirements analysis, database design creation, system design, user interface design, system development, and system testing. The system design method used is OOAD with UML tools. The results of this study include: old business processes, new business processes, context diagrams, system actors, use case lists, use case diagrams, activity diagrams, sequence diagrams, deployment diagrams, and class diagrams. Based on the results of the study, it was concluded that the application was made to carry out login activities, registration of new patients, old patients, storing medical record data and displaying the patient's medical record history in real time when the doctor performed the examination, so as to replace the use of paper medical records and cut patient service time.</em></p>
33
Lakshmi, Seetha, Johonna Asquith, Sally Alrabaa, Mindy Sampson, Natan Kraitman, Garabet Akoghlanian, Maya Balakrishnan, and Beata Casanas. "1310. Improving Infectious Disease Electronic Medical Records Documentation: A Quality Improvement Study in an Academic Teaching Hospital." Open Forum Infectious Diseases 5, suppl_1 (November 2018): S400—S401. http://dx.doi.org/10.1093/ofid/ofy210.1143.
Full textAbstract:
Abstract Background Improving efficiency of documentation and sign outs during transitions of care were identified as areas of interest by the University of South Florida Infectious Disease (ID) Division. Our aim is by May 2018, we will achieve >50% improvement in our ID EMR note efficiency score for any adult patient at Tampa General Hospital. Note efficiency score involves listing all of the following key elements with 1 point awarded for each: active problem in the subjective section, updated hospital course under assessment, active problem prioritized first under assessment and non-relevant problems removed from assessment. Methods Institute of Healthcare Improvement’s model with Plan-Do-Study-Act (PDSA) cycles was used for project implementation from March 2018 to May 2018 (Figure 1). Cycle 1: Conducting a needs assessment survey and education. Cycle 2: Changing the existing template and implementing a new standardized template that includes the key elements, along with removal of auto populated non relevant information. Audits of notes with a 4-point system scoring was done. A pre and post implementation physician survey was conducted. Results ID fellow and faculty completed the baseline survey (N = 25). Less than half (46%) felt that they could interpret patient assessments with ease and even fewer respondents (36%) felt there was adequate weekend sign out. More than one-third (36%) reported writing majority of notes after 5 pm (Figure 1). Pilot project involved nine ID faculty and fellows. We had 95% compliance with use of the standardized EMR template. Notes were evaluated at baseline (n = 190), cycle 1 (n = 85), and cycle 2 (n = 56). An increase in average note efficiency score from baseline, cycle 1 and cycle 2 occurred as follows (Mean ± SD): 2.0 ± 0.84 vs. 2.8 ± 0.95 vs. 3.6 ± 0.5 (Figure 2). Compared with baseline, cycle 2 achieved 42% improvement in the ease of interpretation of patient assessments and 41% improvement in adequate sign out. No increase in note writing after 5pm (36% vs. 30% baseline and cycle 2, respectively) reported. Conclusion Targeted education and changing the EMR note template can achieve improved efficiency of ID note. These efforts to improve documentation enhance physician’s ease of interpretation of patient assessments and sign out during transition of care. Disclosures All authors: No reported disclosures.
34
Stevens, Lindsay A., Natalie M. Pageler, and Jin S. Hahn. "Improved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing Changes." Applied Clinical Informatics 12, no. 03 (May 2021): 582–88. http://dx.doi.org/10.1055/s-0041-1731342.
Full textAbstract:
Abstract Background Medical student note writing is an important part of the training process but has suffered in the electronic health record (EHR) era as a result of student notes being excluded from the billable encounter. The 2018 CMS billing changes allow for medical student notes to be used for billable services provided that physical presence requirements are met, and attending physicians satisfy performance requirements and verify documentation. This has the potential to improve medical student engagement and decrease physician documentation burden. Methods Our institution implemented medical student notes as part of the billable encounter in August 2018 with support of our compliance department. Note characteristics including number, type, length, and time in note were analyzed before and after implementation. Rotating medical students were surveyed regarding their experience following implementation. Results There was a statistically significant increase in the number of student-authored notes following implementation. Attending physicians' interactions with student notes greatly increased following the change (4% of student notes reviewed vs. 84% of student notes). Surveyed students reported that having their notes as part of the billable record made their notes more meaningful and enhanced their learning. The majority of surveyed students also agreed that they received more feedback following the change. Conclusion Medical students are interested in writing notes for education and feedback. Inclusion of their notes as part of the billable record can facilitate their learning and increase their participation in the note writing process.
35
Howanitz, Peter J., and George S. Cembrowski. "Postanalytical Quality Improvement." Archives of Pathology & Laboratory Medicine 124, no. 4 (April 1, 2000): 504–10. http://dx.doi.org/10.5858/2000-124-0504-pqi.
Full textAbstract:
Abstract Objective.—To evaluate elevated patient calcium results as a postanalytic quality indicator of physician practices. Design.—Participants prospectively identified hypercalcemic patient results for 4 months or until they found 320 hypercalcemic results, and then, after at least 3 days, reviewed the medical records of these patients. Hypercalcemia was defined as a calcium value that exceeded the upper limit of each laboratory's reference range by 0.12 mmol/L or more. Participants, as well a subset of their physicians who did not acknowledge or respond to elevated results in the medical record, answered a questionnaire about their practices. Participants.—Five hundred twenty-five laboratories enrolled in the College of American Pathologists Q-Probes program. Main Outcome Measures.—The presence of hyercalcemic results in patients' medical records and physicians' acknowledgement and response to those elevated results. Results.—More than 5500 hypercalcemic results were identified, of which 53.2% represented a new finding. About 3.5% of results were not charted in the patients' records, and 23.1% of patient records did not contain clinician documentation of the abnormal result. Follow-up laboratory tests were not ordered for 13.8% of the elevated values. For 570 of the 808 results for which there was neither clinician documentation nor designated follow-up laboratory tests ordered, patients' physicians received written notification of the elevated calcium results along with a questionnaire. Responses were received from 386 physicians (68%). One hundred physicians indicated they did not order the specific calcium measurement, and of these 100, 85 responded it was part of a panel. The 286 physicians who ordered the test stated the results ultimately led to further testing (69%), a change of management (56%), or a new diagnosis (25%). Conclusions.—We found that a high percentage of abnormal results (3.5%) were not documented in the patients' medical records, the diagnosis of hypercalcemia frequently was new (53.2%), and a high percentage of physicians did not respond to elevated calcium results by writing a note (23.1%) or ordering another test (13.8%). Opportunities for quality improvement at these postanalytical steps are far greater than at the analytical step. Laboratorians must help physicians identify and respond to clinically important laboratory results.
36
曹, 青. "The Process Evaluation Teaching Method Based on Feedback Loop in Medical History Taking and Medical Record Writing of Diagnostics Course." Vocational Education 10, no. 03 (2021): 125–30. http://dx.doi.org/10.12677/ve.2021.103020.
Full text
37
Connor, Jennifer J. "Introduction—Case by Case: Private and Public Representations of Patients in the Grenfell Mission in Newfoundland and Labrador in the Early 20th Century." Canadian Bulletin of Medical History 38, no. 2 (September 1, 2021): 340–71. http://dx.doi.org/10.3138/cbmh.513-022021.
Full textAbstract:
This article provides context for three studies about early 20th-century medical cases in the geographically distributed humanitarian aid organization founded by Wilfred Grenfell in pre-Confederation Newfoundland and Labrador. It situates these studies within historiographical and theoretical approaches to case histories and their publication by medical practitioners, the background for research on the clinical records of the Grenfell organization’s main hospital, and the history behind specific case information for coastal patients. While the cases examined cohere through their organizational origin, the authors of these three studies reveal sometimes unexpected representations of the patient in text and illustration. In these ways, both this introductory article and the following three studies emphasize the enduring appeal of narrative approaches to case writing while also pointing to the evolving ethics of publishing medical reports for general readers and scholars. Together they invite renewed attention to the representation of medical cases in publications that increasingly are available globally in internet collections.
38
Wang, Suxia. "Analysis of the Effect of Applying Various Methods of Teaching Medical Record Writing in the Pre-job Training of Medical Students." Chinese Medical Record English Edition 2, no. 4 (June 2014): 186–89. http://dx.doi.org/10.3109/23256176.2014.927174.
Full text
39
Wang, Jiumin, Peng Li, Luhong Dai, and Linshu Ye. "Analysis and Countermeasures for Writing Quality of Manuals of Medical Records in Outpatient and Emergency in Community Health Service Institutions." Chinese Medical Record English Edition 1, no. 12 (December 2013): 533–35. http://dx.doi.org/10.3109/23256176.2013.882569.
Full text
40
Ho, Minh Tam, Naomi Ghildiyal, Cesar Liendo, Brittany Monceaux, Sheila Asghar, Pratibha Anne, Rupa Koothirezhi, Ugorji Okorie, and Oleg Chernyshev. "856 Sleep-writing, sleep-talking in uncontrolled REM-predominant obstructive sleep apnea." Sleep 44, Supplement_2 (May 1, 2021): A333. http://dx.doi.org/10.1093/sleep/zsab072.853.
Full textAbstract:
Abstract Introduction Abnormal movements and behaviors during sleep are part of a larger group of nocturnal events that may occur during the sleep-wake cycle and/or the transitions into and out of sleep. We are presenting the case of OSA-related confusional arousals associated with sleep-writing and sleep-talking during REM-sleep. Report of case(s) 46 year old female with history of CAD, HTN, RLS, Anxiety, Depression, and REM predominant OSA (AHI of 2.9 per hour of sleep, REM AHI of 40 per hour of sleep, and oxygen saturation nadir of 91%), noncompliant with PAP therapy, returned to reestablish sleep medicine care and restart PAP therapy. The patient reported worsening of her OSA symptoms while being without PAP therapy. In addition to traditional OSA symptoms (snoring, frequent nighttime awakenings, restless legs, daytime sleepiness/fatigue), she reported episodes of sleep-talking, sleep-writing with demonstrated evidence of these events in her personal diary. She maintains a collective diary that incorporates her blood pressure readings, her weight loss accounts with records of meals in a day, as well as a separate log of letters that she will write and mail. In this diary, she has noticed sleep writing instances in each field, with no recollections subsequently on the act of writing them. The patient reported that these episodes of sleep writing would occur 3–4 times in a week, during this period of PAP noncompliance. Last reported instance of her sleep writing was October 2020. After re-initiation of PAP therapy, the patient has not reported further episodes of sleep-writing or sleep-talking. Conclusion The sleep-writing is a very rare clinical symptom in the presentation of REM-predominant OSA as well as in REM/NREM parasomnias. We were not able to come across a case of it in the sleep literature review. Sleep-talking is a well-documented phenomenon. Confusional arousals may be responsible for symptoms of sleep-writing and sleep-talking in this case. We may repeat a sleep study with split protocol and parasomnia montage using AutoBipap if needed to investigate further. Further research should be done to explore the nature and correlation of sleep-writing in clinical practice. Support (if any) N/A
41
Aylor, Megan, Emily M. Campbell, Christiane Winter, and Carrie A. Phillipi. "Resident Notes in an Electronic Health Record." Clinical Pediatrics 56, no. 3 (July 20, 2016): 257–62. http://dx.doi.org/10.1177/0009922816658651.
Full textAbstract:
Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre– and 610 notes post–template introduction were identified. Note length was 263 characters shorter ( P = .004) and mean end time was 73 minutes later ( P < .0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template ( P < .01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR’s contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.
42
Saraswasta, I. Wayan Gede, and Rr Tutik Sri Hariyati. "The Implementation of Electronic based Nursing Care Documentation to EFETEC; A Literature Review." International Journal of Nursing and Health Services (IJNHS) 1, no. 2 (January 3, 2019): 19–31. http://dx.doi.org/10.35654/ijnhs.v1i2.23.
Full textAbstract:
ABSTRACT
In last two decades most of the tasks performed by nurses have not been directly related to patient care. Nurses spend more time on writing documentation or medical records of patients. Implementation of electronic medical record can reduce the time used for documentation or in other hand will increase the time for nurses to interact with patients then eventually can improve the quality of nursing care. Purpose of this literature review is to find out the implementation of electronic-based nursing care documentation (EHR) in improving the quality of nursing care in terms of EFETEC aspects. Method used by author is a literature review. Database used is Science Direct, PROQUEST, Scopus, Ebscho and Scholar Article with the keywords; electronic health record, EHR, Documentation in nursing, Quality of nursing care. Implementation of electronic nursing care documentation can improve the service quality. Improvement of the quality of service is reviewed with EFETEC which consists of efficient, focus for patient, effective, time discipline, equality, confidentiality. In the era of health workers 4.0 the utilization of electronic nursing care documentation requires continuous development in order to improve the quality of service for patients.
KEYWORDS: electronic health record, nursing care documentation, quality of nursing care
43
Shafrir, A. L., L. A. Wise, J. R. Palmer, Z. O. Shuaib, L. M. Katuska, P. Vinayak, M. Kvaskoff, K. L. Terry, and S. A. Missmer. "Validity of self-reported endometriosis: a comparison across four cohorts." Human Reproduction 36, no. 5 (February 17, 2021): 1268–78. http://dx.doi.org/10.1093/humrep/deab012.
Full textAbstract:
Abstract STUDY QUESTION How accurately do women report a diagnosis of endometriosis on self-administered questionnaires? SUMMARY ANSWER Based on the analysis of four international cohorts, women self-report endometriosis fairly accurately with a > 70% confirmation for clinical and surgical records. WHAT IS KNOWN ALREADY The study of complex diseases requires large, diverse population-based samples, and endometriosis is no exception. Due to the difficulty of obtaining medical records for a condition that may have been diagnosed years earlier and for which there is no standardized documentation, reliance on self-report is necessary. Only a few studies have assessed the validity of self-reported endometriosis compared with medical records, with the observed confirmation ranging from 32% to 89%. STUDY DESIGN, SIZE, DURATION We compared questionnaire-reported endometriosis with medical record notation among participants from the Black Women’s Health Study (BWHS; 1995-2013), Etude Epidémiologique auprès de femmes de la Mutuelle Générale de l’Education Nationale (E3N; 1990-2006), Growing Up Today Study (GUTS; 2005–2016), and Nurses’ Health Study II (NHSII; 1989–1993 first wave, 1995–2007 second wave). PARTICIPANTS/MATERIALS, SETTING, METHODS Participants who had reported endometriosis on self-administered questionnaires gave permission to procure and review their clinical, surgical, and pathology medical records, yielding records for 827 women: 225 (BWHS), 168 (E3N), 85 (GUTS), 132 (NHSII first wave), and 217 (NHSII second wave). We abstracted diagnosis confirmation as well as American Fertility Society (AFS) or revised American Society of Reproductive Medicine (rASRM) stage and visualized macro-presentation (e.g. superficial peritoneal, deep endometriosis, endometrioma). For each cohort, we calculated clinical reference to endometriosis, and surgical- and pathologic-confirmation proportions. MAIN RESULTS AND THE ROLE OF CHANCE Confirmation was high—84% overall when combining clinical, surgical, and pathology records (ranging from 72% for BWHS to 95% for GUTS), suggesting that women accurately report if they are told by a physician that they have endometriosis. Among women with self-reported laparoscopic confirmation of their endometriosis diagnosis, confirmation of medical records was extremely high (97% overall, ranging from 95% for NHSII second wave to 100% for NHSII first wave). Importantly, only 42% of medical records included pathology reports, among which histologic confirmation ranged from 76% (GUTS) to 100% (NHSII first wave). Documentation of visualized endometriosis presentation was often absent, and details recorded were inconsistent. AFS or rASRM stage was documented in 44% of NHSII first wave, 13% of NHSII second wave, and 24% of GUTS surgical records. The presence/absence of deep endometriosis was rarely noted in the medical records. LIMITATIONS, REASONS FOR CAUTION Medical record abstraction was conducted separately by cohort-specific investigators, potentially introducing misclassification due to variation in abstraction protocols and interpretation. Additionally, information on the presence/absence of AFS/rASRM stage, deep endometriosis, and histologic findings were not available for all four cohort studies. WIDER IMPLICATIONS OF THE FINDINGS Variation in access to care and differences in disease phenotypes and risk factor distributions among patients with endometriosis necessitates the use of large, diverse population samples to subdivide patients for risk factor, treatment response and discovery of long-term outcomes. Women self-report endometriosis with reasonable accuracy (>70%) and with exceptional accuracy when women are restricted to those who report that their endometriosis had been confirmed by laparoscopic surgery (>94%). Thus, relying on self-reported endometriosis in order to use larger sample sizes of patients with endometriosis appears to be valid, particularly when self-report of laparoscopic confirmation is used as the case definition. However, the paucity of data on histologic findings, AFS/rASRM stage, and endometriosis phenotypic characteristics suggests that a universal requirement for harmonized clinical and surgical data documentation is needed if we hope to obtain the relevant details for subgrouping patients with endometriosis. STUDY FUNDING/COMPETING INTEREST(S) This project was supported by Eunice Kennedy Shriver National Institute of Child Health and Development grants HD48544, HD52473, HD57210, and HD94842, National Cancer Institute grants CA50385, R01CA058420, UM1CA164974, and U01CA176726, and National Heart, Lung, and Blood Institute grant U01HL154386. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AS, SM, and KT were additionally supported by the J. Willard and Alice S. Marriott Foundation. MK was supported by a Marie Curie International Outgoing Fellowship within the 7th European Community Framework Programme (#PIOF-GA-2011-302078) and is grateful to the Philippe Foundation and the Bettencourt-Schueller Foundation for their financial support. Funders had no role in the study design, conduct of the study or data analysis, writing of the report, or decision to submit the article for publication. LA Wise has served as a fibroid consultant for AbbVie, Inc for the last three years and has received in-kind donations (e.g. home pregnancy tests) from Swiss Precision Diagnostics, Sandstone Diagnostics, Kindara.com, and FertilityFriend.com for the PRESTO cohort. SA Missmer serves as an advisory board member for AbbVie and a single working group service for Roche; neither are related to this study. No other authors have a conflict of interest to report. Funders had no role in the study design, conduct of the study or data analysis, writing of the report, or decision to submit the article for publication. TRIAL REGISTRATION NUMBER N/A.
44
Venkat, K. K. "Short and sweet: Writing better consult notes in the era of the electronic medical record." Cleveland Clinic Journal of Medicine 82, no. 1 (January 2015): 13–17. http://dx.doi.org/10.3949/ccjm.82a.14008.
Full text
45
Berg, Marc. "Practices of reading and writing: the constitutive role of the patient record in medical work." Sociology of Health and Illness 18, no. 4 (September 1996): 499–524. http://dx.doi.org/10.1111/1467-9566.ep10939100.
Full text
46
Lai, Pei Fang, Ying Fang Zhou, and Pin Shou Chen. "The Experience of Using Informational Systems to Improve the ACLS Process Optimization in the Emergency Department." Prehospital and Disaster Medicine 34, s1 (May 2019): s131. http://dx.doi.org/10.1017/s1049023x19002863.
Full textAbstract:
Introduction:The best first-aid treatment for cardiac arrest patients is Advanced Cardiac Life Support (ACLS) to not only hope to save lives but to also leave minimal sequelae. The American Heart Association (AHA) published updated ACLS guidelines for care in 2015 emphasizing the concept of teamwork in resuscitation. However, the actual use of ACLS is not easy due to stress and unfamiliarity with the process.Aim:Therefore, we want to use the information technology to assist the medical team to implement the ACLS process. This information system can help us to save time and labor, as well as increase precision. In addition to this, data analysis is more convenient, which facilitates the management and supervision of resuscitation quality.Methods:An information system was developed using responsive web design (RWD) website. It can be used on a variety of devices, such as desktops, tablets, or mobile phones, and can be updated simultaneously. The system requires non-synchronous operation to be used in a wireless network environment. When the information system is in operation, the medical personnel can perform the resuscitation actions according to voice prompts, which can periodically remind staff to check rhythm, give correct medication dose, and identify whether defibrillation shock is needed. At the same time, the entire process can be recorded instantly. After the file is uploaded, the medical records are complete at the same time.Results:After 3 months, the satisfaction of medical staff reached 80.3%, the rate of return of spontaneous circulation (ROSC) of OHCA cases elevated to 45% from 15%, and discharge without neurological sequelae elevated to 33% from 27.4%.Discussion:All hospital staff can use this system to assist in the correct implementation of advanced CPR. It improves the quality of resuscitation and reduces the burden on clinical and writing medical records of medical staff.
47
Sun, Ya Li, Tian Rong Yu, and Ji Hong Wang. "College Students' Innovative Thinking Ability Training Process and the Observation Result." Applied Mechanics and Materials 672-674 (October 2014): 2241–44. http://dx.doi.org/10.4028/www.scientific.net/amm.672-674.2241.
Full textAbstract:
Objective In the process of improving college students' innovative thinking ability, Using the method of case writing standardization to promote college students' innovative thinking ability of ascension .Method: In view of the college of nursing level 2011 nursing undergraduate class (1.2) 76 students, 76 students as a group to take use of their spare time to participate in the writing process of standardized cases , And repeated modification, strict review, Finally through the teacher group carefully proofread and a series of writing process. This period of time for 3 months . Class 3 of 34 students as control group adopts the traditional learning style, After school time for autonomous learning ,Final for two class students the theoretical achievements of the paper comparative analysis .Result: Participate in the standardization of medical record writing students understanding ,application and cases analysis topic average score in the final internal medicine nursing papers, significantly higher than that of the control group students conclusion : Experimental cases of students through standardized writing process, greatly improve college students comprehensive analysis thinking ability , In the final examination paper understand applied exam scores are significantly higher than the control group, So is to participate in medical record writing process to exert positive effects on college students' innovative thinking ability training .
48
Meskó, Bertalan. "The Real Era of the Art of Medicine Begins with Artificial Intelligence." Journal of Medical Internet Research 21, no. 11 (November 18, 2019): e16295. http://dx.doi.org/10.2196/16295.
Full textAbstract:
Physicians have been performing the art of medicine for hundreds of years, and since the ancient era, patients have turned to physicians for help, advice, and cures. When the fathers of medicine started writing down their experience, knowledge, and observations, treating medical conditions became a structured process, with textbooks and professors sharing their methods over generations. After evidence-based medicine was established as the new form of medical science, the art and science of medicine had to be connected. As a result, by the end of the 20th century, health care had become highly dependent on technology. From electronic medical records, telemedicine, three-dimensional printing, algorithms, and sensors, technology has started to influence medical decisions and the lives of patients. While digital health technologies might be considered a threat to the art of medicine, I argue that advanced technologies, such as artificial intelligence, will initiate the real era of the art of medicine. Through the use of reinforcement learning, artificial intelligence could become the stethoscope of the 21st century. If we embrace these tools, the real art of medicine will begin now with the era of artificial intelligence.
49
Burrows, Daron. "“Ele boute son doi en son con…”." Reinardus / Yearbook of the International Reynard Society 27 (December 31, 2015): 33–57. http://dx.doi.org/10.1075/rein.27.02bur.
Full textAbstract:
Across the Middle Ages, Continental French texts satirised the French spoken by Englishmen, with particular comic value attached to their alleged tendency unwittingly to use foutre and other obscene terms. Since the Anglophones’ jargon relies on grotesque parody of attested morpho-syntactical and phonological features of Insular French, this article assesses whether there may also be a lexical kernel of truth underlying the satire by exploring the frequency and context of occurrence of specific items of sexual vocabulary in Anglo-Norman texts, including fabliaux, comic monologues and dialogues, courtly narratives, manières de langage, word-lists and glosses, legal records, and medical writing.
50
van der Haak, M., M. Hartmann, R. Haux, P. Schmücker, and R. Brandner. "Electronic Signature for Medical Documents – Integration and Evaluation of a Public Key Infrastructure in Hospitals." Methods of Information in Medicine 41, no. 04 (2002): 321–30. http://dx.doi.org/10.1055/s-0038-1634389.
Full textAbstract:
Summary Objectives: Our objectives were to determine the user-oriented and legal requirements for a Public Key Infrastructure (PKI) for electronic signatures for medical documents, and to translate these requirements into a general model for a signature system. A prototype of this model was then implemented and evaluated in clinical routine use. Methods: Analyses of documents, processes, interviews, observations, and of the available literature supplied the foundations for the development of the signature system model. Eight participants of the Department of Dermatology of the Heidelberg University Medical Center evaluated the implemented prototype from December 2000 to January 2001, during the course of an intervention study. By means of questionnaires, interviews, observations and database analyses, the usefulness and user acceptance of the electronic signature and its integration into electronic discharge letters were established. Results: Since the major part of medical documents generated in a hospital are signature-relevant, they will require electronic signatures in the future. A PKI must meet the multitude of responsibilities and security needs required in a hospital. Also, the signature functionality must be integrated directly into the workflow surrounding document creation. A developed signature model, fulfilling user-oriented and legal requirements, was implemented using hard and software components that conform to the German Signature Law. It was integrated into the existing hospital information system of the Heidelberg University Medical Center. At the end of the intervention study, the average acceptance scores achieved were x = 3,90; sD = 0,42 on a scale of 1 (very negative attitude) to 5 (very positive attitude) for the electronic signature procedure. Acceptance of the integration into computer-supported discharge letter writing reached x = 3,91; sD = 0,47. On average, the discharge letters were completed 7.18 days earlier. Conclusion: The electronic signature is indispensable for the further development of electronic patient records. Application-independent hard and software components, in accordance with the signature law, must be integrated into electronic patient records, and provided to certification services using standardized interfaces. Signature-oriented workflow and document management components are essential for user acceptance in routine clinical use.