Journal articles: 'Quality record'

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Velásquez, D., and L. M. Giraldo. "Diffraction Efficiency Adjustment to Record High Quality Color Holograms." Ingeniería y Ciencia 11, no. 22 (July 31, 2015): 9–23. http://dx.doi.org/10.17230/ingciencia.11.22.1.

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In this article, we report the experimental values of required exposureto obtain the maximum diffraction efficiencies in PFG-03C Slavich filmon independent recordings and RGB multiplexed recordings. Also, coloradjustments by modifying wavelength channels contribution on reflectiondiffraction gratings, and color composition changes on Denisyuk hologramsobserved by using different spectral compositions light sources were studiedand presented.

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

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

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Rendarti, Rindi. "Faktor-Faktor yang Mempengaruhi Mutu Pelayanan Rekam Medis di Rumah Sakit." Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat 14, no. 2 (November 4, 2019): 59. http://dx.doi.org/10.32504/sm.v14i2.125.

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Background: Medical record units as part of supporting medical services in hospitals have an important role in improving the quality of services in hospitals. The indicator of service quality in hospital is measured by incomplete inpatient medical record files. Based on several studies in various hospitals, the complete of inpatient medical record files is around 70% - 80% from 100%. Based on the preliminary data in action research in PKU Muhammadiyah hospital, there were 60 % incomplete in filling the medical resume from 100% target. There are many things that occurred, one of them are about human resources that is affected by behavior, the implementation of operational standards in filling medical records, punish and reward files. Objective: To review the factors that affect the quality of service in medical record units related to improving the quality of hospital services. Methods: the method of this study used relevant health databases including Scholars by using a combination of terms: hospital service quality indicators, incompleteness in filling medical medical records, quality of medical record services. Results: The result of this study said that there were related between medical record services and quality of hospital services. The quality indicator in the medical record can be able to be measured was the number of incomplete filling in medical record files. Filling of incomplete medical record files has the potential to reduce the overall quality of hospital services Keywords: quality of medical record services, quality of hospital medical services, incomplete medical record filling

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Jia, Xiaoyan, Hongjiu Zhou, Lijuan Chen, and Dongmin Li. "Influence of Medical Record Quality Control on Terminal Medical Record Quality of the Nephrology Department." Chinese Medical Record English Edition 2, no. 3 (April 2014): 120–22. http://dx.doi.org/10.3109/23256176.2014.912008.

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Seymour, Tom, Dean Frantsvog, and Tod Graeber. "Electronic Health Records (EHR)." American Journal of Health Sciences (AJHS) 3, no. 3 (July 13, 2012): 201–10. http://dx.doi.org/10.19030/ajhs.v3i3.7139.

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Electronic Health Records are electronic versions of patients’ healthcare records. An electronic health record gathers, creates, and stores the health record electronically. The electronic health record has been slow to be adopted by healthcare providers. The federal government has recently passed legislation requiring the use of electronic records or face monetary penalties. The electronic health record will improve clinical documentation, quality, healthcare utilization tracking, billing and coding, and make health records portable. The core components of an electronic health record include administrative functions, computerized physician order entry, lab systems, radiology systems, pharmacy systems, and clinical documentation. HL7 is the standard communication protocol technology that an electronic health record utilizes. Implementation of software, hardware, and IT networks are important for a successful electronic health record project. The benefits of an electronic health record include a gain in healthcare efficiencies, large gains in quality and safety, and lower healthcare costs for consumers. Electronic health record challenges include costly software packages, system security, patient confidentiality, and unknown future government regulations. Future technologies for electronic health records include bar coding, radio-frequency identification, and speech recognition.

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Reiter, Jerome. "Data Quality and Record Linkage Techniques." Journal of the American Statistical Association 103, no. 482 (June 1, 2008): 881. http://dx.doi.org/10.1198/jasa.2008.s229.

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

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

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Stergachis, Andy S. "Record Linkage Studies for Postmarketing Drug Surveillance: Data Quality and Validity Considerations." Drug Intelligence & Clinical Pharmacy 22, no. 2 (February 1988): 157–61. http://dx.doi.org/10.1177/106002808802200216.

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Large automated databases are the source of information for many record linkage studies, including postmarketing drug surveillance. Despite this reliance on prerecorded data, there have been few attempts to assess data quality and validity. This article presents some of the basic data quality and validity issues in applying record linkage methods to postmarketing surveillance. Studies based on prerecorded data, as in most record linkage studies, have all the inherent problems of the data from which they are derived. Sources of threats to the validity of record linkage studies include the completeness of data, the ability to accurately identify and follow the records of individuals through time and place, and the validity of data. This article also describes techniques for evaluating data quality and validity. Postmarketing surveillance could benefit from more attention to identifying and solving the problems associated with record linkage studies.

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Nowak, Robert, Wiktor Franus, Jiarui Zhang, Yue Zhu, Xin Tian, Zhouxian Zhang, Xu Chen, and Xiaoyu Liu. "Record Linkage of Chinese Patent Inventors and Authors of Scientific Articles." Applied Sciences 11, no. 18 (September 10, 2021): 8417. http://dx.doi.org/10.3390/app11188417.

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We present an algorithm to find corresponding authors of patents and scientific articles. The authors are given as records in Scopus and the Chinese Patents Database. This issue is known as the record linkage problem, defined as finding and linking individual records from separate databases that refer to the same real-world entity. The presented solution is based on a record linkage framework combined with text feature extraction and machine learning techniques. The main challenges were low data quality, lack of common record identifiers, and a limited number of other attributes shared by both data sources. Matching based solely on an exact comparison of authors’ names does not solve the records linking problem because many Chinese authors share the same full name. Moreover, the English spelling of Chinese names is not standardized in the analyzed data. Three ideas on how to extend attribute sets and improve record linkage quality were proposed: (1) fuzzy matching of names, (2) comparison of abstracts of patents and articles, (3) comparison of scientists’ main research areas calculated using all metadata available. The presented solution was evaluated in terms of matching quality and complexity on ≈250,000 record pairs linked by human experts. The results of numerical experiments show that the proposed strategies increase the quality of record linkage compared to typical solutions.

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Mô Dang, Van, Patrice François, Pierre Batailler, Arnaud Seigneurin, Jean-Philippe Vittoz, Elodie Sellier, and José Labarère. "Medical record-keeping and patient perception of hospital care quality." International Journal of Health Care Quality Assurance 27, no. 6 (July 8, 2014): 531–43. http://dx.doi.org/10.1108/ijhcqa-06-2013-0072.

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Purpose – Medical record represents the main information support used by healthcare providers. The purpose of this paper is to examine whether patient perception of hospital care quality related to compliance with medical-record keeping. Design/methodology/approach – The authors merged the original data collected as part of a nationwide audit of medical records with overall and subscale perception scores (range 0-100, with higher scores denoting better rating) computed for 191 respondents to a cross-sectional survey of patients discharged from a university hospital. Findings – The median overall patient perception score was 77 (25th-75th percentiles, 68-87) and differed according to the presence of discharge summary completed within eight days of discharge (81 v. 75, p=0.03 after adjusting for baseline patient and hospital stay characteristics). No independent associations were found between patient perception scores and the documentation of pain assessment and nutritional disorder screening. Yet, medical record-keeping quality was independently associated with higher patient perception scores for the nurses’ interpersonal and technical skills component. Research limitations/implications – First, this was a single-center study conducted in a large full-teaching hospital and the findings may not apply to other facilities. Second, the analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, the authors could not investigate whether electronic medical record contributed to better compliance with recording standards and eventually higher patient perception scores. Practical implications – Because of the potential consequences of poor recording for patient safety, further efforts are warranted to improve the accuracy and completeness of documentation in medical records. Originality/value – A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care.

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Winter, Alfred, Katsuhiko Takabayashi, Franziska Jahn, Eizen Kimura, Rolf Engelbrecht, Reinhold Haux, Masayuki Honda, et al. "Quality Requirements for Electronic Health Record Systems." Methods of Information in Medicine 56, S 01 (January 2017): e92-e104. http://dx.doi.org/10.3414/me17-05-0002.

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SummaryBackground: For more than 30 years, there has been close cooperation between Japanese and German scientists with regard to information systems in health care. Collaboration has been formalized by an agreement between the respective scientific associations. Following this agreement, two joint workshops took place to explore the similarities and differences of electronic health record systems (EHRS) against the background of the two national healthcare systems that share many commonalities.Objectives: To establish a framework and requirements for the quality of EHRS that may also serve as a basis for comparing different EHRS.Methods: Donabedian’s three dimensions of quality of medical care were adapted to the outcome, process, and structural quality of EHRS and their management. These quality dimensions were proposed before the first workshop of EHRS experts and enriched during the discussions.Results: The Quality Requirements Framework of EHRS (QRF-EHRS) was defined and complemented by requirements for high quality EHRS. The framework integrates three quality dimensions (outcome, process, and structural quality), three layers of information systems (processes and data, applications, and physical tools) and three dimensions of information management (strategic, tactical, and operational information management).Conclusions: Describing and comparing the quality of EHRS is in fact a multidimensional problem as given by the QRF-EHRS framework. This framework will be utilized to compare Japanese and German EHRS, notably those that were presented at the second workshop.

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Benton, M. J., M. A. Wills, and R. Hitchin. "Quality of the fossil record through time." Nature 403, no. 6769 (February 2000): 534–37. http://dx.doi.org/10.1038/35000558.

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Zwiebel, F. M., and T. Sauerbruch. "Quality Assurance by Computerized Endoscopy Record Systems." Endoscopy 24, S 2 (July 1992): 527–31. http://dx.doi.org/10.1055/s-2007-1010536.

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Martin, Carol Ann. "Improving the Quality of Medical Record Documentation." Journal For Healthcare Quality 14, no. 3 (May 1992): 16–23. http://dx.doi.org/10.1111/j.1945-1474.1992.tb00032.x.

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Scruth, Elizabeth Ann. "Quality Nursing Documentation in the Medical Record." Clinical Nurse Specialist 28, no. 6 (2014): 312–14. http://dx.doi.org/10.1097/nur.0000000000000085.

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Scruth, Elizabeth Ann, and Rayne Soriano. "Quality Documentation in the Electronic Medical Record." Clinical Nurse Specialist 30, no. 4 (2016): 190–93. http://dx.doi.org/10.1097/nur.0000000000000214.

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Dewi, Cindy Kusuma. "PENILAIAN KUALITAS INFORMASI DOKUMEN REKAM MEDIS RAWAT JALAN." Jurnal Administrasi Kesehatan Indonesia 5, no. 1 (December 20, 2017): 21. http://dx.doi.org/10.20473/jaki.v5i1.2017.21-31.

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Performance evaluation was showed that average service time from January to October 2016 was 35.56 minutes. The average service time ensuring provision of medical records of outpatients was under targets because the standard of service time of the Minister of Health No. 129 at 2008 is <10 minutes. This research aimed to determine the information quality of medical record documents outpatients as helped efforts to improve the information quality of medical record documents. This was a descriptive study with cross-sectional design. Data was collected through observation outpatient medical record on December. The samples consisted 115 medical record documents. The sampling method used was random sampling. Variable used by researchers was the quality dimensions of The Product and Service Performance for Information Quality Model. The results showed the dimensions free of error of 68.33%, dimensions of concise representation of 58.44%, and the dimensions of completeness by 55.56%, and dimensions of consistent representation of 52.22%. Based on research result, average score of information quality assessment were good enough. Recommendation for Medical Record Departementbased on research results was made guidelines or standard operating procedures could be used to increase the quality of medical record documents. Keywords: assessment, dimension, information quality, Medical Record Document,outpatient

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Raza, Arif. "Use of CRABEL Scores to improve Quality of Medical Records Documentation in Hospitals." International Journal of Research Foundation of Hospital and Healthcare Administration 4, no. 1 (2016): 5–10. http://dx.doi.org/10.5005/jp-journals-10035-1052.

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ABSTRACT Introduction This study is based on an approach employed by a medical college hospital for improving the adequacy of documentation in their medical records. The hospital utilized CRABEL scoring tool to screen and score their medical records and then used this information as a feedback to their clinical departments for encouraging them to improve their record documentation. Aim The study aims to determine whether the approach of the hospital resulted in any significant change in adequacy of their medical record documentation. Materials and methods Baseline sample of 250 current medical records (stratified random) from four clinical departments were scored using CRABEL scoring method to determine baseline average score and number of files with high scores (score > 0.85). Feedbacks on scores were given to departments, along with the information on areas for improvement. Scoring and feedback were repeated every month for six consecutive months, with sample size of 230 to 271. Trends in average score and number of files with high scores were observed. Difference between average scores of baseline sample and sample at the end of 6 months was statistically tested. Number of files with high scores, in departments where approach was carried out was compared with number of files with high scores, in departments were approach was not carried out, to check statistically significant difference, if any Results The trend showed a continuous monthly improvement in both average scores and number of files with high scores. Improvement was found in files of all clinical departments with minor variations. The chi-square test and Student's t test showed a significant difference at p < 0.05 (p for chi square — 0.001 and for t-test — 0.04). Conclusion The hospital's approach was found to be successful in improving the adequacy of documentation in medical records. Clinical significance Medical record constitutes the most important record in a clinical setting. Completeness of medical record is essential for proper patient care, but is a challenge in most organization. The approach has proven successful in this study and can be replicated in other settings for improvement. How to cite this article Raza A. Use of CRABEL Scores to improve Quality of Medical Records Documentation in Hospitals. Int J Res Foundation Hosp Healthc Adm 2016;4(1):5-10.

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Blayney, D. W., G. Miela, D. Markstrom, D. Hanauer, K. McNiff, and M. Neuss. "Measuring quality with the Quality Oncology Practice Initiative (QOPI) at a university comprehensive cancer center." Journal of Clinical Oncology 25, no. 18_suppl (June 20, 2007): 6535. http://dx.doi.org/10.1200/jco.2007.25.18_suppl.6535.

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6535 Background: QOPI is a tool which measures adherence to both guidelines and to process for use in quality improvement. QOPI was designed and pilot tested predominately in physician office practices [Neuss et al, JCO 23:6233]. We tested QOPI at UMCCC, a large, hospital-based, academic cancer center, where medical documents are stored in a free-text electronic record, in a paper-based hospital record, and in clinic charts. In 2006, 136 physicians and 58 mid-level practitioners provided 66,699 clinic visits and oversaw 37,500 infusion visits. Methods: The tumor registry selected consecutive cases of breast (BrCa), lung, and colorectal cancer (CRC), and lymphoma (L), diagnosed between minus 6 and minus 30 months from day 0 of each QOPI round. Forty charts with each tumor type and 40 deceased patient records were identified for each round. A clinical pharmacist accessed the pharmacy database to obtain drug data, and the tumor registrar abstracted the three other chart formats, using an electronic text search tool [Hanauer et al Proc ASCO 2006 abs 6080] for the electronic record. De-identified data were submitted to a secure, ASCO-hosted server, for analysis. Results: In the Spring 2006 round, 163 charts yielding 1641 measures required 148 hours of abstractor effort, for an average of 54 minutes (mins) per chart and 5.4 mins per measure. In the Fall, 2006 round, 236 charts yielding 2334 measures required 256.5 hours of effort for 65 mins per chart and 6.6 mins per measure. For comparison, a survey of QOPI practices for the Fall round yielded 29 mins per chart. UMCCC treatment (Rx) and process measures are shown in the table . Conclusions: Abstracting for QOPI measures, using abstractors not involved in patient care, is labor intensive but feasible at a large cancer center. QOPI has allowed UMCCC to assess concordance with guidelines and other quality measures, provides comparison data to other practices, and identifies processes for improvement. The evolution of QOPI will include data transfer from electronic records. [Table: see text] [Table: see text]

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C. David, Gary, Donald Chand, and Balaji Sankaranarayanan. "Error rates in physician dictation: quality assurance and medical record production." International Journal of Health Care Quality Assurance 27, no. 2 (March 3, 2014): 99–110. http://dx.doi.org/10.1108/ijhcqa-06-2012-0056.

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Purpose – The purpose of the paper is to determine the instance of errors made in physician dictation of medical records. Design/methodology/approach – Purposive sampling method was employed to select medical transcriptionists (MTs) as “experts” to identify the frequency and types of medical errors in dictation files. Seventy-nine MTs examined 2,391 dictation files during one standard work day, and used a common template to record errors. Findings – The results demonstrated that on the average, on the order of 315,000 errors in one million dictations were surfaced. This shows that medical errors occur in dictation, and quality assurance measures are needed in dealing with those errors. Research limitations/implications – There was no potential for inter-coder reliability and confirming the error codes assigned by individual MTs. This study only examined the presence of errors in the dictation-transcription model. Finally, the project was done with the cooperation of MTSOs and transcription industry organizations. Practical implications – Anecdotal evidence points to the belief that records created directly by physicians alone will have fewer errors and thus be more accurate. This research demonstrates this is not necessarily the case when it comes to physician dictation. As a result, the place of quality assurance in the medical record production workflow needs to be carefully considered before implementing a “once-and-done” (i.e. physician-based) model of record creation. Originality/value – No other research has been published on the presence of errors or classification of errors in physician dictation. The paper questions the assumption that direct physician creation of medical records in the absence of secondary QA processes will result in higher quality documentation and fewer medical errors.

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Tola, Kasu, Haftom Abebe, Yemane Gebremariam, and Birhanu Jikamo. "Improving Completeness of Inpatient Medical Records in Menelik II Referral Hospital, Addis Ababa, Ethiopia." Advances in Public Health 2017 (2017): 1–5. http://dx.doi.org/10.1155/2017/8389414.

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Introduction. The incompleteness of medical records is a significant problem that affects the quality of health care services in many hospitals of Ethiopia. Improving the completeness of patient’s records is an important step towards improving the quality of healthcare. Methods. Pre- and postintervention study was conducted to assess improvement of inpatient medical record completeness in Menelik II Referral Hospital from September 2015 to April 2016. Simple random sampling technique was used. Data was collected using data extraction checklist and independent sample t-test was used to compare statistical difference that exists between pre- and postintervention outcomes at confidence interval of 95% and P value less than 0.05 was considered statistically significant. Result. The overall inpatient medical record completeness was found to be 84% after intervention. An enhancement of completeness and reporting of inpatient medical record completeness increased significantly from the baseline 73% to 84% during postintervention evaluation at P value < 0.05. Conclusion and Recommendation. The finding of this project suggests that a simple set of interventions comprising inpatient medical record format and training healthcare provider showed a significant improvement in inpatient medical record completeness. The Quality Officer and Chief Executive Officer of the study hospital are recommended to design and launch intervention programs to improve medical record completeness.

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Boonratsamee, Nattinee, Sutham Pinjaroen, and Chitkasaem Suwanrath. "Completeness of data record in the obstetric record form." Songklanagarind Medical Journal 35, no. 2 (May 25, 2017): 169. http://dx.doi.org/10.31584/smj.2017.35.2.699.

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Objective: To survey the completeness of obstetric data records.Material and Method: A survey study was conducted to determine the completeness of obstetric data records of women who delivered at Songklanagarind Hospital from January 1, to June 30, 2012 in the obstetric data record forms of the Statistical Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University. The data consisted of 5 parts including general information, obstetric history, pregnancy outcome, complications andoperative obstetrics with indications. Rates of completeness by recorders were calculated.Results: A total of 1,698 obstetric data records were evaluated. The overall rate of completeness was 10.1%. The rates of completeness of the general information (part 1), recorded by nurses, and the clinical part (parts 2 to 5), recorded by physicians, were 36.7% and 26.1%. The intern had the highest rate of completeness, followed by the extern and the resident.Conclusion: The rate of completeness of obstetric data records was low. The feedback report will be sent to theDepartment of Obstetrics and Gynecology to find out an appropriate strategy to improve quality of electronic databasefor future use in research and quality service management.

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Triananda, Besse Lizanty, Indahwaty Sidin, Masni Masni, Syahrir A. Pasinringi, Fridawaty Rivai, and Rachmat Latief. "Factors Related to Completeness of Completion and Timeliness of Returning Medical Record Files in Inpatients at Tarakan Hospital." Journal Wetenskap Health 2, no. 2 (August 2, 2021): 62–73. http://dx.doi.org/10.48173/jwh.v2i2.119.

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Medical record is a subsystem of the hospital information system as a whole which has a very important role in improving the quality and service in hospitals. This study aims to analyze the factors related to the completeness of filling and the timeliness of returning medical record files for inpatients at Tarakan Hospital. This type of research is a quantitative study using an observational study with a cross sectional study design. Sampling used total sampling so that the sample in this study were doctors at the Inpatient Installation of Tarakan Hospital, totaling 38 respondents. The results showed that there was a relationship between individual characteristics, organizational characteristics, job characteristics and SOPs with the completeness of filling out medical record files and the timeliness of returning medical record files at Tarakan Hospital. Therefore, it is hoped that the hospital management will continue to improve monitoring and evaluation of the importance of maintaining the quality of medical records, then immediately switch to electronic medical records in order to solve problems that exist in the medical record unit, so that performance improvements and service quality in hospitals can be realized. Tarakan which has an impact on increasing patient satisfaction and loyalty

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Núñez Zarazú, Llermé, Bibiana León Huerta, and Olga Giovanna Valderrama-Ríos. "Comparison of traditional and automated nursing records in the medicine services of the Callejón de Huaylas hospitals - Peru [Comparación de los registros de enfermería tradicionales y automatizados en los servicios de medicina de los hospitales del Callejón de Huaylas – Perú]." Journal of Global Health and Medicine 5, no. 1 (March 3, 2021): 1. http://dx.doi.org/10.32829/ghmj.v5i1.217.

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The objective of this study was to compare the quality of traditional and automated nursing records in the medical services of four hospitals in Callejón de Huaylas - Peru. Investigation of quantitative approach quasi experimental. The population consisted of 32,940 nursing records from the medical records, and the sample consisted of 816 records, selected by stratified probability sampling. The instruments used were; Quality inventory of the nursing record and the software called the Automated Nursing Record System (SIARE) version 1.0. The results show that the difference in quality of the traditional and automated nursing records, with the student's t test obtained a mean of 7.284, a SD of 1.172, a t value = 29.815, with d.f. 22 and a p value = 0.000, resulting in significant differences between the quality scores of the traditional and automated nursing records of the medicine services of the hospitals of the Callejón de Huaylas. It is concluded that the quality (structure, continuity of care and patient safety) of the automated records is high in comparison with traditional nursing records.

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

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

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Berkowitz, C. D. "Toward a Quality Workforce: Setting the Record Straight." PEDIATRICS 112, no. 2 (August 1, 2003): 418–19. http://dx.doi.org/10.1542/peds.112.2.418.

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Baiotto, Barbara, Christian Bracco, Sara Bresciani, Antonella Mastantuoni, Pietro Gabriele, and Michele Stasi. "Quality Assurance of a Record-and-Verify System." Tumori Journal 95, no. 4 (July 2009): 467–72. http://dx.doi.org/10.1177/030089160909500410.

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Aims and background With the introduction of more complex three-dimensional conformal radiotherapy and intensity-modulated radiotherapy techniques in clinical practice, the use of record-and-verify systems is recommended to improve the accuracy of radiotherapy treatments. The aim of the present study was to evaluate, for a commercial record-and-verify system, the efficiency, integration with the treatment planning system, and impact of manual checking of data. The most frequent errors or misses were also evaluated. Materials and methods The development of internal protocols to systematically implement new technologies has been identified as a priority in the departmental quality assurance process. Data electronically fed into the record-and-verify system were compared with those manually recorded in the clinical paper chart over a period of almost 6 years (October 2000 to December 2006). A total of 7768 treated patients was reviewed. The check was performed by using a homemade data base in which the errors are stratified as follows: 1) general section, 2) geometric and dosimetric section, and 3) delivered dose section. Results On a total of 7768 checked patients, one or more mismatches between treatment planning system data and record-and-verify system data or paper chart data were observed for 452 patients (5.8% of total number of inspected patients). The percentage of discrepancies out of the total was: 2.2% in the general section, 3.3% in the dosimetric and geometric section, and 4.2% in the delivered-dose section. Conclusions Although record-and-verify systems assume a crucial role in the accuracy and reproducibility of radiation treatment, their inability to eradicate all the errors requires vigilance on the part of the radiation therapy and physics team.

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Fogg, Maj Jason T., and Col Earl W. Ferguson. "Using Quality Service Analysts to Streamline Record Reviews." Journal For Healthcare Quality 16, no. 6 (November 1994): 25–27. http://dx.doi.org/10.1111/j.1945-1474.1994.tb00744.x.

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Durkin, Nancy. "Using Record Review as a Quality Improvement Process." Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional 24, no. 8 (September 2006): 492–502. http://dx.doi.org/10.1097/00004045-200609000-00006.

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&NA;. "Using Record Review as a Quality Improvement Process." Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional 24, no. 8 (September 2006): 503–4. http://dx.doi.org/10.1097/00004045-200609000-00007.

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Hider, Philip, and Kah-Ching Tan. "Constructing Record Quality Measures Based on Catalog Use." Cataloging & Classification Quarterly 46, no. 4 (September 2008): 338–61. http://dx.doi.org/10.1080/01639370802322515.

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Kelly Jr., W. G. "Correcting the Record on the Data Quality Act." Science 319, no. 5860 (January 11, 2008): 158b—159b. http://dx.doi.org/10.1126/science.319.5860.158b.

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Horsley, Scott W. "Golf Courses and Water Quality - The Track Record." Groundwater Monitoring & Remediation 16, no. 1 (February 1996): 54–55. http://dx.doi.org/10.1111/j.1745-6592.1996.tb00567.x.

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Chen, Chun-Ming, Kun-Tsung Lee, and Yee-Hsiung Shen. "Simple method to record high-quality surgical videos." British Journal of Oral and Maxillofacial Surgery 47, no. 6 (September 2009): 494. http://dx.doi.org/10.1016/j.bjoms.2009.03.004.

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Guha, Abhik, S. Aslam, N. Barham, and J. Brand. "Quality of anaesthetic record keeping for thoracic procedures." Journal of Cardiothoracic and Vascular Anesthesia 32 (August 2018): S37. http://dx.doi.org/10.1053/j.jvca.2018.08.083.

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Stark, Robert James. "The Quality of the Archaeological Record (Charles Perreault)." Canadian Journal of Archaeology 44, no. 2 (2020): 271–73. http://dx.doi.org/10.51270/44.2.271.

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Faraji-Khiavi, Farzad, Saiedeh Sharifi, Mansour Zahiri, and Hosein Dargahi. "Medical record documentation quality in the hospital accreditation." Journal of Education and Health Promotion 10, no. 1 (2021): 76. http://dx.doi.org/10.4103/jehp.jehp_852_20.

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Knaup, P. "Section 2: Patient Records: Electronic Patient Records and their Benefit for Patient Care." Yearbook of Medical Informatics 15, no. 01 (August 2006): 40–42. http://dx.doi.org/10.1055/s-0038-1638475.

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SummaryTo summarize current excellent research in the field of patient records.Synopsis of the articles selected for the IMIA Yearbook 2006.Current research in the field of patient records analyses users’ needs and attitudes as well as the potential and limitations of electronic patient record systems. Particular topics are the questions physicians have when assessing patients during ward rounds, the timeliness of results when ordered electronically, the quality of documenting haemophilia home therapy, attitudes towards patient access to health records and adequate strategies for record linkage in dependence on the intended purpose.The best paper selection of articles on patient records shows examples of excellent research on methods used for the management of patient records and for processing their content as well as assessing the potential, limitations of and user attitudes towards electronic patient record systems. Computerized patient records are mature, so that they can contribute to high quality patient care and efficient patient management.

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Zegers, M., M. C. de Bruijne, P. Spreeuwenberg, C. Wagner, P. P. Groenewegen, and G. van der Wal. "Quality of patient record keeping: an indicator of the quality of care?" BMJ Quality & Safety 20, no. 4 (February 8, 2011): 314–18. http://dx.doi.org/10.1136/bmjqs.2009.038976.

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Koh, Justin, and Mansoor Ahmed. "Improving clinical documentation: introduction of electronic health records in paediatrics." BMJ Open Quality 10, no. 1 (February 2021): e000918. http://dx.doi.org/10.1136/bmjoq-2020-000918.

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Medical records are crucial facet of a patient’s journey. These provide the clinician with a permanent record of the patient’s illness and ongoing medical care, thus enabling informed clinical decisions. In many hospitals, patient medical records are written on paper. However, written notes are liable to misinterpretation due to illegibility and misplacement. This can affect the patient’s medical care and has medico-legal implications. Electronic patient records (EPR) have been gradually introduced to replace patient’s paper notes with the aim of providing a more reliable record-keeping system. It is perceived that EPR improve the quality and efficiency of patient care. The paediatric department at Queen’s Hospital Burton uses a mix of paper notes and computerised medical records. Clinicians primarily use paper notes for admission clerking, ward rounds, ward reviews and outpatient clinic consultations. Laboratory tests, imaging results and prescription requests are executed via the EPR system. Documentation by nurses is also carried out electronically. We aimed to improve and standardise clinical documentation of paediatric admissions and ward round notes by developing electronic proforma for initial paediatric clerking, ward rounds and patient reviews. This quality improvement project improved clinical documentation on the paediatric wards and enhanced patient record-keeping, boosted clinical information-sharing and streamlined patient journey. It fulfilled various generic multidisciplinary record keeping audit tool standards endorsed by the Royal College of Physicians by 100%. We undertook a staff survey to investigate the opinion before and after implementing the electronic health record. Doctors, nurses and healthcare support workers overwhelmingly supported the quality, usefulness, completeness of specified fields and practicality of the electronic records.

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Zieniewicz, Iwona. "The quality of contemporary records made by handwriting. Comparative analysis over the period of nineteen years." Nowa Kodyfikacja Prawa Karnego 47 (August 3, 2018): 115–26. http://dx.doi.org/10.19195/2084-5065.47.9.

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Handwriting is a method to express and preserve thoughts by means of graphic signs. In the investigative and judicial practice, it is treated as an individual creation used for identification purposes in case of doubts over the authenticity of a written record. Nowadays, however, writing by hand is not the only way of conveying information, which results in moving away from this traditional method in favour of modern solutions. In the future, this tendency may limit the possibility to identify the author of a record on the basis of a handwritten record. Therefore, the purpose of this publication is to check whether contemporary handwritings show any signs of deterioration in the quality of handwritten records.

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Olson, Kristen, Xiaoyu Lin, and Timothy Banks. "Evaluating Data Quality in Reports of Sales in a Retail Establishment Survey." International Journal of Market Research 59, no. 3 (May 2017): 301–19. http://dx.doi.org/10.2501/ijmr-2017-025.

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This paper examines failure to use records in sales reporting across about 12,000 store owners participating in a retail measurement panel in a Southeast Asian country. Reported sales based on the storekeeper's memory (oral reports) were lower than those from records, as expected. More surprisingly, oral reports acted as a supplement to record-based reports at the same store, such that stores that had oral reports had higher total sales than those with invoices. Although stores were expected to either have or not have a reliable record system, many stores used both. Findings varied over individual categories of products. Little research has examined the quality of reports of retail (consumer) sales from store owners in non-western countries. The paper suggests that improving data collection tools, rather than a single statistical adjustment approach, may be a more fruitful avenue for reducing measurement error in sales reports.

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Ritonga, Zulham Andi, Ida Yustina, and Destanul Aulia. "THE RELATIONSHIP BETWEEN PROCEDURE AND SUPERVISION ON THE QUALITY OF MEDICAL RECORD IN IMELDA HOSPITAL." International Journal of Nursing and Health Services (IJNHS) 2, no. 3 (September 15, 2019): 180–88. http://dx.doi.org/10.35654/ijnhs.v2i3.230.

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The quality of a good medical record must meet the indicators of completeness and accuracy of filling, timeliness in safety and provision of medical records that meet legal requirements. The purpose of this study was to analyze the influence of procedures and supervision on the quality medical records for inpatient. This research is survey research with explanatory research design. The research was conducted at Imelda Hospital. The research population was 238 people and the sample was 100 people. The sampling technique is stratified random sampling which divides the population into homogeneous groups (strata) proportionally: 21 doctors, 65 nurses, and 14 medical records officers, from each stratum a random sample is taken. Data analysis using univariate, bivariate with the chi-square test, and multivariate using multiple logistic regression tests. The results showed that the procedure factor had no effect on the quality of medical records at the Imelda Hospital, p-value 0.520> 0.05. The controlling factor influences the quality of medical records at Imelda Hospital, p-value 0.001 <0.05. The hospital implements routine surveillance with evaluations every week, every month, every six months, and every year so that medical records become of high quality, that is, medical records are complete, accurate, returned on time, and meet legal requirements. Keywords: medical record quality of Inpatient Care, Supervision, Procedure

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Seaman, Jennifer B., Anna C. Evans, Andrea M. Sciulli, Amber E. Barnato, Susan M. Sereika, and Mary Beth Happ. "Abstracting ICU Nursing Care Quality Data From the Electronic Health Record." Western Journal of Nursing Research 39, no. 9 (September 7, 2016): 1271–88. http://dx.doi.org/10.1177/0193945916665814.

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The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen’s kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.

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Zullig, Leah L., Kristin Schroeder, Pilli Nyindo, Theresia Namwai, Elvis Silayo, Angelah Msomba, Michael Oresto Munishi, et al. "Validation and Quality Assessment of the Kilimanjaro Cancer Registry." Journal of Global Oncology 2, no. 6 (December 2016): 381–86. http://dx.doi.org/10.1200/jgo.2015.002873.

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Purpose Global cancer burden has increasingly shifted to low- and middle-income countries and is particularly pronounced in Africa. There remains a lack of comprehensive cancer information as a result of limited cancer registry development. In Moshi, Tanzania, a regional cancer registry exists at Kilimanjaro Christian Medical Center. Data quality is unknown. Our objective was to evaluate the completeness and quality of the Kilimanjaro Cancer Registry (KCR). Methods In October 2015, we conducted a retrospective review of KCR by validating the internal consistency of registry records with medical and pathology records. We randomly sampled approximately 100 total registry cases. Four reviewers not associated with the KCR manually collected data elements from medical records and compared them with KCR data. Results All 100 reviewed registry cases had complete cancer site and morphology included in the registry. Six had a recorded stage. For the majority (n = 92), the basis of diagnosis was pathology. Pathology reports were found in the medical record for 40% of patients; for the remainder, these were stored separately in the pathology department. Of sampled registry cases, the KCR and medical records were 98% and 94% concordant for primary cancer site and morphology, respectively. For 28%, recorded diagnosis dates were within 14 days of what was found in the medical record, and for 32%, they were within 30 days. Conclusion The KCR has a high level of concordance for classification and coding when data are retrieved for validation. This parameter is one of the most important for measuring data quality in a regional cancer registry.

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Belbin, Lee, Arthur Chapman, John Wieczorek, Paula Zermoglio, Alex Thompson, and Paul Morris. "Data Quality Task Group 2: Tests and Assertions." Biodiversity Information Science and Standards 2 (May 18, 2018): e25608. http://dx.doi.org/10.3897/biss.2.25608.

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Task Group 2 of the TDWG Data Quality Interest Group aims to provide a standard suite of tests and resulting assertions that can assist with filtering occurrence records for as many applications as possible. Currently ‘data aggregators’ such as the Global Biodiversity Information Facility (GBIF), the Atlas of Living Australia (ALA) and iDigBio run their own suite of tests over records received and report the results of these tests (the assertions): there is, however, no standard reporting mechanisms. We reasoned that the availability of an internationally agreed set of tests would encourage implementations by the aggregators, and at the data sources (museums, herbaria and others) so that issues could be detected and corrected early in the process. All the tests are limited to Darwin Core terms. The ~95 tests refined from over 250 in use around the world, were classified into four output types: validations, notifications, amendments and measures. Validations test one of more Darwin Core terms, for example, that dwc:decimalLatitude is in a valid range (i.e. between -90 and +90 inclusive). Notifications report a status that a user of the record should know about, for example, if there is a user-annotation associated with the record. Amendments are made to one or more Darwin Core terms when the information across the record can be improved, for example, if there is no value for dwc:scientificName, it can be filled in from a valid dwc:taxonID. Measures report values that may be useful for assessing the overall quality of a record, for example, the number of validation tests passed. Evaluation of the tests was complex and time-consuming, but the important parameters of each test have been consistently documented. Each test has a globally unique identifier, a label, an output type, a resource type, the Darwin Core terms used, a description, a dimension (from the Framework on Data Quality from TG1), an example, references, implementations (if any), test-prerequisites and notes. For each test, generic code is being written that should be easy for institutions to implement – be they aggregators or data custodians. A valuable product of the work of TG2 has been a set of general principles. One example is “Darwin Core terms are either: literal verbatim (e.g., dwc:verbatimLocality) and cannot be assumed capable of validation, open-ended (e.g., dwc:behavior) and cannot be assumed capable of validation, or bounded by an agreed vocabulary or extents, and therefore capable of validation (e.g., dwc:countryCode)”. Another is “criteria for including tests is that they are informative, relatively simple to implement, mandatory for amendments and have power in that they will not likely result in 0% or 100% of all record hits.” A third: “Do not ascribe precision where it is unknown.” GBIF, the ALA and iDigBio have committed to implementing the tests once they have been finalized. We are confident that many museums and herbaria will also implement the tests over time. We anticipate that demonstration code and a test dataset that will validate the code will be available on project completion.

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Li, Chao, Yuanyuan Ge, Jingjing Dou, Xiwu Xu, and Pengcheng Sun. "Influence of Implementation of Electronic Medical Record System on Medical Record Quality and Cause Analysis." Chinese Medical Record English Edition 1, no. 11 (November 2013): 455–58. http://dx.doi.org/10.3109/23256176.2013.877695.

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Neuss, Michael N., Christopher E. Desch, Kristen K. McNiff, Peter D. Eisenberg, Dean H. Gesme, Joseph O. Jacobson, Mohammad Jahanzeb, et al. "A Process for Measuring the Quality of Cancer Care: The Quality Oncology Practice Initiative." Journal of Clinical Oncology 23, no. 25 (September 1, 2005): 6233–39. http://dx.doi.org/10.1200/jco.2005.05.948.

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Purpose The Quality Oncology Practice Initiative (QOPI) is a practice-based system of quality self-assessment sponsored by the participants and the American Society of Clinical Oncology (ASCO). The process of quality evaluation, development of the pilot questionnaire, and preliminary results are reported. Methods Physicians from seven oncology groups developed medical record abstraction measures based on practice guidelines and consensus-supported indicators of quality care. Each practice completed two rounds of records review and received practice and aggregate results. Mean frequencies of responses for each indicator were compared among practices. Results Participants universally, if informally, find QOPI helpful, and results show statistically significant variation among practices for several indicators, including assessing pain in patients close to death, documentation of informed consent for chemotherapy, and concordance with granulocytic and erythroid growth factor administration guidelines. Measures with universally high concordance include the use of serotonin antagonist antiemetics according to the ASCO guideline; the presence of a pathology report in the record; the use of chemotherapy flow sheets; and adherence to standard chemotherapy recommendations for patients with certain stages of breast, colon, and rectal cancer. Concordance with quality indicators significantly changed between survey rounds for several measures. Conclusion Pilot results indicate that the QOPI process provides a rapid and objective measurement of practice quality that allows comparisons among practices and over time. It also provides a mechanism for measuring concordance with published guidelines. Most importantly, it provides a tool for practice self-examination that can promote excellence in cancer care.

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Guiver, Tenniel, Sean Randall, Anna Ferrante, James Semmens, Phil Anderson, Teresa Dickinson, and James Boyd. "A Simple Sampling Method for Estimating the Accuracy of Large Scale Record Linkage Projects." Methods of Information in Medicine 55, no. 03 (2016): 276–83. http://dx.doi.org/10.3414/me15-01-0152.

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SummaryBackground: Record linkage techniques allow different data collections to be brought together to provide a wider picture of the health status of individuals. Ensuring high linkage quality is important to guarantee the quality and integrity of research. Current methods for measuring linkage quality typically focus on precision (the proportion of incorrect links), given the difficulty of measuring the proportion of false negatives.Objectives: The aim of this work is to introduce and evaluate a sampling based method to estimate both precision and recall following record linkage.Methods: In the sampling based method, record-pairs from each threshold (including those below the identified cut-off for acceptance) are sampled and clerically reviewed. These results are then applied to the entire set of record-pairs, providing estimates of false positives and false negatives. This method was evaluated on a synthetically generated dataset, where the true match status (which records belonged to the same person) was known.Results: The sampled estimates of linkage quality were relatively close to actual linkage quality metrics calculated for the whole synthetic dataset. The precision and recall measures for seven reviewers were very consistent with little variation in the clerical assessment results (overall agreement using the Fleiss Kappa statistics was 0.601).Conclusions: This method presents as a possible means of accurately estimating matching quality and refining linkages in population level linkage studies. The sampling approach is especially important for large project linkages where the number of record pairs produced may be very large often running into millions.

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Rosenbaum, Diane L., Margaret H. Clark, Alexandra D. Convertino, Christine C. Call, Evan M. Forman, and Meghan L. Butryn. "Examination of Nutrition Literacy and Quality of Self-monitoring in Behavioral Weight Loss." Annals of Behavioral Medicine 52, no. 9 (January 25, 2018): 809–16. http://dx.doi.org/10.1093/abm/kax052.

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Abstract Background Few have examined nutrition literacy (i.e., capacity to process and make informed nutritional decisions) in behavioral weight loss. Nutrition literacy (NL) may impact necessary skills for weight loss, contributing to outcome disparities. Purpose The study sets out to identify correlates of NL; evaluate whether NL predicted weight loss, food record completion and quality, and session attendance; and investigate whether the relations of race and education to weight loss were mediated by NL and self-monitoring. Methods This is a secondary analysis of 6-month behavioral weight loss program in which overweight/obese adults (N = 320) completed a baseline measure of NL (i.e., Newest Vital Sign). Participants self-monitored caloric intake via food records. Results NL was lower for black participants (p < .001) and participants with less education (p = .002). Better NL predicted better 6-month weight loss (b = −.63, p = .04) and food record quality (r = .37, p < .001), but not food record completion or attendance (ps > 0.05). Black participants had lower NL, which was associated with poorer food record quality, which adversely affected weight loss. There was no indirect effect of education on weight loss through NL and food record quality. Conclusions Overall, results suggest that lower NL is problematic for weight loss. For black participants, NL may indirectly impact weight loss through quality of self-monitoring. This might be one explanation for poorer behavioral weight loss outcomes among black participants. Additional research should investigate whether addressing these skills through enhanced treatment improves outcomes. Clinical trial information NCT02363010.

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Journal articles on the topic 'Quality record'

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