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1

Abdekhoda, Mohammadhiwa, Afsaneh Dehnad, Alireza Noruzi, Mahmodreza Gohari, and Maryam Ahmadi. "Applying Electronic Medical Records in health care." Applied Clinical Informatics 07, no. 02 (2016): 341–54. http://dx.doi.org/10.4338/aci-2015-11-ra-0165.

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SummaryIn order to fulfill comprehensive interoperability and recognize the electronic medical records (EMRs’) benefits, physicians’ attitudes toward using and applying EMR must be recognized.The purpose of this study was to present an integrated model of applying EMRs by physicians.This was a cross sectional study in which a sample of 330 physicians working in hospitals affiliated to the Tehran University of medical sciences (TUMS) was selected. Physicians’ attitudes toward using and accepting EMR in health care have been analyzed by an integrated model of two classical theories i.e. technolo
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2

Md Zali, Mastura, Saiful Farik Mat Yatin, Mohd Razilan Abdul Kadir, Siti Noraini Mohd Tobi, Nurul Hanis Kamarudin, and Nik Nurul Emyliana Nik Ramlee. "Managing Medical Records in Specialist Medical Centres." International Journal of Engineering & Technology 7, no. 3.7 (2018): 232. http://dx.doi.org/10.14419/ijet.v7i3.7.16358.

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A collection of facts about a patient’s life and health history of past and present illnesses and treatments is known as medical records. The health professionals were contributing to record the patient’s care. The responsibility in managing daily records that produced by each of department is by the Medical Records Department. It is a department under clinical support services with activities including managing of patient records, patient information production, management of medical reports, and hospital statistics. This article aims to discuss the challenge associated with managing medical
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Gozali, Elahe, Marjan Ghazisaiedi, Malihe Sadeghi, and Reza Safdari. "Improvement of patient safety through implementation of electronic medical records." Medical Technologies Journal 1, no. 4 (2017): 111–12. http://dx.doi.org/10.26415/2572-004x-vol1iss4p111-112.

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Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advan
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Silalahi, Rani Gartika Holivia, and Ermawaty Arisandi Siallagan. "PENGETAHUAN MAHASISWA DIII KEBIDANAN STIKES SANTA ELISABETH MEDAN TENTANG KELENGKAPAN PENCATATAN REKAM MEDIS." Elisabeth Health Jurnal 3, no. 2 (2018): 58–62. http://dx.doi.org/10.52317/ehj.v3i2.247.

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Hospitals as one of the health care facilities are required to make medical records. Medical records are written evidence of services provided by doctors that contain patient identity, examination, treatment, other actions and services that have been given to patients. Midwives as medical personnel who also provide health services have an obligation to make documentation of their midwifery care actions. Aim: This study aimed to analyze the relationship of midwifery DIII student knowledge about medical records with the completeness of filling in midwifery care documentation. Methode: This resea
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Kazley, Abby S., and Yasar A. Ozcan. "Do Hospitals With Electronic Medical Records (EMRs) Provide Higher Quality Care?" Medical Care Research and Review 65, no. 4 (2008): 496–513. http://dx.doi.org/10.1177/1077558707313437.

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Marutha, Ngoako Solomon, and Mpho Ngoepe. "Medical records management framework to support public healthcare services in Limpopo province of South Africa." Records Management Journal 28, no. 2 (2018): 187–203. http://dx.doi.org/10.1108/rmj-10-2017-0030.

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Purpose This study aims to develop a framework for the management of medical records in support of health-care service delivery in the hospitals in the Limpopo province of South Africa. Design/methodology/approach The study was predominantly quantitative and has used the questionnaires, system analysis, document analysis and observation to collect data in 40 hospitals of Limpopo province. The sample of 49 per cent (306) records management officials were drawn out of 622 (100 per cent) total population. The response rate was 71 per cent (217) out of the entire sample. Findings The study discove
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7

Merz, Jon F., Pamela Sankar, and Simon S. Yoo. "Hospital Consent for Disclosure of Medical Records." Journal of Law, Medicine & Ethics 26, no. 3 (1998): 241–48. http://dx.doi.org/10.1111/j.1748-720x.1998.tb01425.x.

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Physicians and other health care providers owe ethical and legal duties to patients to maintain the secrecy of the information learned during the course of patient care. This obligation is fulfilled by limiting access to such information to only those involved in the patient's care-that is, to those within the “circle of confidentiality.” As a general rule, providers may only disclose to others with the written prior consent of the patient. Exceptions may be “ethically and legally justified because of overriding social considerations,” when permitted or compelled by law. For example, eleven st
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8

Lapina, A. K., O. N. Arharova, T. S. Rodina, and V. D. Vagner. "ON THE QUESTION ORTHODONTIC MEDICAL RECORDS COMPLETION WHEN DENTOALVEOLAR ANOMALIES AND DEFORMATIONS DIAGNOSING." I.P. Pavlov Russian Medical Biological Herald 25, no. 2 (2017): 279–88. http://dx.doi.org/10.23888/pavlovj20172279-288.

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Correct registration of primary medical documentation is very important for storage of diagnostic information, the treatment plan, information about the carrying out of medical manipulations for the elimination of dentofacial anomalies, for examination of quality of medical care in conflict situations. Medical card of the orthodontic patient (form 043- 1/у), approved by order of Ministry of Health of the Russian Federation On approval of unified forms of medical records used in medical organizations providing medical care in outpatient conditions and procedures for their filling from 15.12.201
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Mishra, Amit Kumar, Shiva Bhattarai, Partha Bhurtel, et al. "Need for Improvement of Medical Records." Journal of Nepal Medical Association 48, no. 174 (2009): 103–6. http://dx.doi.org/10.31729/jnma.222.

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Introduction: A medical record is a systematic documentation of a patient’s medical history and care for legal and future use. A poor quality medical record can negatively affect patient care and safety. The study aims to assess the adequacy of medical records in Bir Hospital, a central hospital.Methods:A cross-sectional study was conducted by analyzing consecutive discharge summaries of patients admitted during a 6 month period in a single unit of a tertiary care center. The discharge summary format of the hospital was taken as the standard and evaluation for adequacy of data entered was asse
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10

Camacho, Luiz Antonio Bastos, and Haya Rahel Rubin. "Reliability of medical audit in quality assessment of medical care." Cadernos de Saúde Pública 12, suppl 2 (1996): S85—S93. http://dx.doi.org/10.1590/s0102-311x1996000600009.

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Medical audit of hospital records has been a major component of quality of care assessment, although physician judgment is known to have low reliability. We estimated interrater agreement of quality assessment in a sample of patients with cardiac conditions admitted to an American teaching hospital. Physician-reviewers used structured review methods designed to improve quality assessment based on judgment. Chance-corrected agreement for the items considered more relevant to process and outcome of care ranged from low to moderate (0.2 to 0.6), depending on the review item and the principal diag
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Ufitinema, Yvonne, Rex Wong, Eva Adomako, Léonard Kanyamarere, Egide Kayonga Ntagungira, and Jeanne Kagwiza. "Increasing patient medical record completion by assigning nurses to specific patients in maternity ward at Munini hospital." On the Horizon 24, no. 4 (2016): 327–34. http://dx.doi.org/10.1108/oth-07-2016-0040.

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Purpose The purpose of this paper is to describe the quality improvement project to increase the medical record documentation completion rate in a district hospital in Rwanda. Despite the importance of medical records to support high quality and efficient care, incomplete documentation is common in many hospitals. Design/methodology/approach The pre- and post-intervention record completion rate in the maternity unit was assessed. Intervention included assigned nurse to specific patients, developed guideline, provided trainings and supervisions. Findings The documentation completion rate signif
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Bonner, Joseph, Brandon Stange, Mindy Kjar, et al. "Interdisciplinary Plans of Care, Electronic Medical Record Systems, and Inpatient Mortality." ACI Open 02, no. 01 (2018): e21-e29. http://dx.doi.org/10.1055/s-0038-1653970.

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Background Interdisciplinary plans of care (IPOCs) guide care standardization and satisfy accreditation requirements. Yet patient outcomes associated with IPOC usage through an electronic medical record (EMR) are not present in the literature. EMR systems facilitate the documentation of IPOC use and produce data to evaluate patient outcomes. Objectives This article aimed to evaluate whether IPOC-guided care as documented in an EMR is associated with inpatient mortality. Methods We contrasted whether IPOC-guided care was associated with a patient being discharged alive. We further tested whethe
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Rowlands, Stella, Steven Coverdale, and Joanne Callen. "Documentation of clinical care in hospital patients’ medical records." Health Information Management Journal 45, no. 3 (2016): 99–106. http://dx.doi.org/10.1177/1833358316639448.

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Background: Clinical documentation is essential for communication between health professionals and the provision of quality care to patients. Objective: To examine medical students’ perspectives of their education in documentation of clinical care in hospital patients’ medical records. Method: A qualitative design using semi-structured interviews with fourth-year medical students was undertaken at a hospital-based clinical school in an Australian university. Results: Several themes reflecting medical students’ clinical documentation education emerged from the data: formal clinical documentatio
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14

Dooling, Catherine, and Alan Wolff. "Limited Adverse Occurrence Screening: A Program with Significant Benefits for the Medical Record Department." Australian Medical Record Journal 22, no. 3 (1992): 98–101. http://dx.doi.org/10.1177/183335839202200305.

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Quality is a major issue in industry. However, the performance of hospitals is predominantly measured by quantity. There is little accurate measurement of, and control over, the quality of patient care provided. Traditional medical quality assurance methods do not meet the basic criteria of an effective control system as defined in management theory. Occurrence screening is a method of medical quality control that overcomes many of these deficiencies. It detects adverse patient occurrences by screening medical records using outcome criteria and selective medical record review. The implementati
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Kim, SuJin, Seulji Ku, Taerim Kim, Won Chul Cha, and Kwang Yul Jung. "Effective Use of Mobile Electronic Medical Records by Medical Interns in Real Clinical Settings: Mixed Methods Study." JMIR mHealth and uHealth 8, no. 12 (2020): e23622. http://dx.doi.org/10.2196/23622.

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Background In South Korea, most graduated medical students undertake a 1-year internship before beginning residency and specialization. Interns usually work in a tertiary hospital and rotate between different, randomly assigned departments to be exposed to different medical specialties. Their jobs are mostly simple and repetitive but are still essential for the patient care process. However, owing to the lack of experience and overwhelming workload, interns at tertiary hospitals in South Korea are usually inefficient, often delaying the entire clinical process. Health care providers have widel
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Dujat, C., R. Haux, P. Schmücker, and A. Winter. "Digital Optical Archiving of Medical Records in Hospital Information Systems – A Practical Approach Towards the Computer-based Patient Record?" Methods of Information in Medicine 34, no. 05 (1995): 489–97. http://dx.doi.org/10.1055/s-0038-1634622.

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Abstract:The large number of inpatients and outpatients in university hospitals leads to high costs of medical documentation and to an increasing number of medical documents. Due to legal regulations, these medical records have to be stored for 30 years. This implies spatial, organizational, and economical problems. At present, conventional archiving in hospitals often does not satisfy the need to make medical records available for healthcare professionals in a systematic and timely manner. From 1989 to 1993 a pilot study on “digital optical archiving of medical records” was carried out at Hei
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17

Ho, La, Nguyen, et al. "Health Care, Medical Insurance, and Economic Destitution: A Dataset of 1042 Stories." Data 4, no. 2 (2019): 57. http://dx.doi.org/10.3390/data4020057.

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The dataset contains 1042 records obtained from inpatients at hospitals in the northern region of Vietnam. The survey process lasted 20 months from August 2014 to March 2016, and yielded a comprehensive set of records of inpatients’ financial situations, healthcare, and health insurance information, as well as their perspectives on treatment service in the hospitals. Five articles were published based on the smaller subsets. This data article introduces the full dataset for the first time and suggests a new Bayesian statistics approach for data analysis. The full dataset is expected to contrib
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18

Yazawa, Kazuyuki, Yukihiro Kamijo, Ryuichi Sakai, Masahiko Ohashi, and Mafumi Owa. "Medical Care for a Mass Gathering: The Suwa Onbashira Festival." Prehospital and Disaster Medicine 22, no. 5 (2007): 431–35. http://dx.doi.org/10.1017/s1049023x00005161.

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AbstractIntroduction:The Suwa Onbashira Festival is held every six years and draws approximately one million spectators from across Japan. Men ride the Onbashira pillars (logs) down steep slopes.At each festival, several people are crushed under the heavy log. During the 2004 festival, for the first time, a medical care system that coordinated a medical team, an emergency medical service, related agencies, and local hospitals was constructed.Objective:The aims of this study were to characterize the spectrum of injuries and illness and to evaluate the medical care system of this festival.Method
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19

Choi, Yuri, June-sung Kim, In Ho Kwon, et al. "Development of a Mobile Personal Health Record Application Designed for Emergency Care in Korea; Integrated Information from Multicenter Electronic Medical Records." Applied Sciences 10, no. 19 (2020): 6711. http://dx.doi.org/10.3390/app10196711.

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Collecting patient’s medical data is essential for emergency care. Although hospital-tethered personal health records (PHRs) can provide accurate data, they are not available as electronic information when the hospital does not develop and supply PHRs. The objective of this research was to evaluate whether a mobile app can assemble health data from different hospitals and enable interoperability. Moreover, we identified numerous barriers to overcome for putting health data into one place. The new mobile PHR (mPHR) application was developed and evaluated according to the four phases of the syst
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Mô Dang, Van, Patrice François, Pierre Batailler, et al. "Medical record-keeping and patient perception of hospital care quality." International Journal of Health Care Quality Assurance 27, no. 6 (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 overa
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Rodríguez-Vera, F. Javier, Y. Marín, A. Sánchez, C. Borrachero, and E. Pujol. "Illegible Handwriting in Medical Records." Journal of the Royal Society of Medicine 95, no. 11 (2002): 545–46. http://dx.doi.org/10.1177/014107680209501105.

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In clinical records many items are handwritten and difficult to read. We examined clinical histories in a representative sample of case notes from a Spanish general hospital. Two independent observers assigned legibility scores, and a third adjudicated in case of disagreement. Defects of legibility such that the whole was unclear were present in 18 (15%) of 117 reports, and were particularly frequent in records from surgical departments. Through poor handwriting, much information in medical records is inaccessible to auditors, to researchers, and to other clinicians involved in the patient's c
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Maria Ulfa, Henny. "Peningkatan Pencapaian Nilai Akreditasi Pelayanan Rekam Medis Rumah Sakit Lancang Kuning Pekanbaru Tahun 201." Jurnal Kesehatan Komunitas 2, no. 1 (2012): 9–13. http://dx.doi.org/10.25311/keskom.vol2.iss1.35.

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In an effort to improve the quality of care, the hospital must conduct periodic accreditation at least every three years. Standard hospital services meet five basic service activities, namely administration and management, medical services, emergency services, nursing services, medical record services and each hospital has a duty to carry medical records. Preliminary data indicate that the assessment parameter passing grade accreditation service medical records are lacking. The purpose of this study to find out how to increase the value of the parameter Hospital medical service record Lancang
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Pereira, Daniel Augusto, and Rodrigo Reina Muñoz. "Information System for Integrated Medical Records with Access via IOT Technology." International Journal of Emerging Technology and Advanced Engineering 11, no. 4 (2021): 6–17. http://dx.doi.org/10.46338/ijetae0421_02.

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The objective of this project was the development of an information management system for healthcare purpose using cloud computing and IoT technology. The system was designed to receive data coming from medical instruments, as well as documents issued by healthcare professionals and doctor responsible for the care of a patient. For medical consultation, patients must use an identification card that allows access to the corresponding medical history stored in the cloud. This access can be done through an RFID reader, making it possible to consult patient information on a human-machine interface
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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
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Lander, Kevin, and Jonathan Pritchett. "When to Care." Social Science History 33, no. 2 (2009): 155–82. http://dx.doi.org/10.1017/s0145553200010944.

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Prior to the Civil War, many hospitals in the southern United States treated both free and slave patients. In this article we develop a model for the selective medical treatment of slaves. We argue that the pecuniary benefits of hospital care increased with the price of the slave if healthy. Using a rich sample of admission records from New Orleans Touro Hospital, we find a positive correlation between the predicted price of the slave and the probability of hospital admission. We test the robustness of the model by controlling for the length of residence in the city, ownership by traders and d
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Teufel, Ronald J., Abby Swanson Kazley, Annie L. Andrews, Myla D. Ebeling, and William T. Basco. "Electronic Medical Record Adoption in Hospitals That Care for Children." Academic Pediatrics 13, no. 3 (2013): 259–63. http://dx.doi.org/10.1016/j.acap.2013.01.010.

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Mardyantari, Etik, Sandu Siyoto, and Sentot Imam Suprapto. "Analysis of Internal Customer Satisfaction Related to the Service of the Medical Record at Muhammadiyah Public Hospital Ponorogo." Journal for Quality in Public Health 4, no. 2 (2021): 181–87. http://dx.doi.org/10.30994/jqph.v4i2.206.

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The medical record department is one of the most important parts in the hospital's effort to provide excellent service to patients. The medical records section is indeed a part that is not directly involved in patient care, but other health workers need a medical record section in order to serve patients. The purpose of this study was to analyze internal customer satisfaction related to the service of the medical records department at Muhammadiyah Hospital Ponorogo. The research design used a descriptive quantitative research design. The sampling technique used was snowball sampling. The resul
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Rosengren, Kristina, Kerstin Ulin, and Eric Carlström. "Characteristic of person-centered care as documented in medical records at a medical department – a mixed methods." Journal of Hospital Administration 8, no. 2 (2019): 7. http://dx.doi.org/10.5430/jha.v8n2p7.

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Objective: Few studies describe characteristics of content of person-centrered care (PCC) in hospital care. Therefore, this study aim to describe and compare documentation in medical records regarding content of PCC for two diagnostic groups; Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure (CHF) at a medical department in a hospital in Sweden.Methods: Documentation within medical records (n = 121) regarding content of PCC (patient resources, responsibility, i.e. partnership) were analysed by a mixed methods.Results: The results describe documented healthcare activities (
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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 (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
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Epstein, Nancy E. "What Can Spine Surgeons Do to Improve Patient Care and Avoid Medical Negligence Suits?" Surgical Neurology International 11 (March 6, 2020): 38. http://dx.doi.org/10.25259/sni_28_2020.

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Background: Why do patients sue following spine surgery? Here we reviewed some of the most frequent reasons for medical negligence suits against surgeons, adjunctive medical personnel, and or institutions/hospitals. Methods: Summarizing the multiple reasons for suits against spine surgeons, their colleagues/consultants, and hospitals should help surgeons identify the problems leading to suits, and improve patient care. Results: Several of the most common reasons for medical negligence suits include: lack of informed consent, ghost surgery, failure to diagnose and treat (e.g. including preopera
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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
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Missah, Yaw Marfo, Parag Dighe, Monty G. Miller, and Kenneth Wall. "Implementation of Electronic Medical Records—A Case Study of an Eye Hospital." South Asian Journal of Business and Management Cases 2, no. 1 (2013): 97–113. http://dx.doi.org/10.1177/2277977913480682.

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Health care organizations around the world are recognizing the benefits of maintaining electronic medical records for patients with improved quality of service, free flow of information (across multiple locations), reduced cost of operations resulting in cost efficiencies, better health and efficient utilization of resources. Recognizing these benefits as opportunities, health care providers have or are in the process of migrating from paper-based health care records to electronic medical systems. This transition is not always free from challenges. This study presents recommendations for manag
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Shikina, Irina, and David Davidov. "Assessment of the quality of medical care provided to patients in a psychiatric hospital." Vestnik of Saint Petersburg University. Medicine 15, no. 4 (2020): 274–82. http://dx.doi.org/10.21638/spbu11.2020.405.

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Monitoring and evaluation of the quality of medical care provided to patients is essential in any medical specialty, but especially in relation to specialized care in mental health hospitals. The aim of our work is to assess the quality of specialized medical care provided to patients in the psychiatric hospital. We have examined 270 medical records and internal quality control cards of patients hospitalized from 2015 to 2019 in the Psychiatric Clinical Hospital No. 4 of the Moscow Healthcare Department (hereinafter referred to as “PCH No. 4” of MHD). The quality control of the provided medica
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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 (2020): 423–33. http://dx.doi.org/10.30994/jqph.v3i2.92.

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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 resource
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Tumbinskaya, Lidia V., Olga V. Yashchina, and Marina Yu Gerasimenko. "Analysis of medical records in a specialized osteopathic clinic in Moscow." Russian Journal of Physiotherapy, Balneology and Rehabilitation 18, no. 1 (2019): 28–32. http://dx.doi.org/10.17816/1681-3456-2019-18-1-28-32.

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Introduction. In clinics, hospitals, public and private hospitals, it is necessary to ensure that documentation meets all the requirements of the industry regulator. Registration, maintenance, systematization, storage of medical documentation is a specific and difficult task, it serves as a means of proving the conduct of medical, diagnostic and other specialized procedures. Medical documents serve as a tool for monitoring the quality of medical services provided, confirming the fact of assistance and revealing its essence.
 The goal is to conduct internal quality control of medical docum
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Ganslandt, T., and H. U. Prokosch. "Perspectives for Medical Informatics." Methods of Information in Medicine 48, no. 01 (2009): 38–44. http://dx.doi.org/10.3414/me9132.

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Summary Objectives: Even though today most university hospitals have already implemented commercial hospital information systems and started to build up comprehensive electronic medical records, reuse of such data for data warehousing and research purposes is still very rare. Given this situation, the focus of this paper is to present an overview on exemplary projects, which have already tackled this challenge, reflect on current initiatives within the United States of America and the European Union to establish IT infrastructures for clinical and translational research, and draw attention to
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Amir, Nabbilah. "Legal Protection of Patient Data Confidentiality Electronic Medical Records." SOEPRA 5, no. 2 (2020): 198. http://dx.doi.org/10.24167/shk.v5i2.2427.

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The use of electronic devices is inseparable from life today, entering the Industrial Revolution era where technological sophistication can replace human tasks, so the use of electronic devices can not only be found in domestic life, offices, and education but also in medical services. The various facilities offered by health care providers both hospitals and clinics in the form of technology utilization are increasingly rapidly becoming one of the electronic medical records that are expected to have a positive impact on reducing paper use. Medical records that used paper (conventional) were c
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38

Hrechanyk, O. I., and R. Ya Abdullaiev. "ANALYSIS OF SHORTCOMINGS IN MEDICAL CARE PROVIDING TO SERVICEMEN IN THE NATIONAL MILITARY MEDICAL CLINICAL CENTER "MAIN MILITARY CLINICAL HOSPITAL"." International Medical Journal, no. 2 (July 15, 2020): 77–80. http://dx.doi.org/10.37436/2308-5274-2020-2-15.

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Assessing the quality of medical care, identifying defects in its provision, studying the shortcomings of medical activities are extremely important not only for forensic expertise or law enforcement practice, but also for all clinical medicine. For the purpose of clinical and anatomical analysis as well as the creation of classification of medical errors which most often occur in the conditions of military medical and preventive institution, revealing of their reasons in National military medical clinical center "Main military clinical hospital" (Kyiv) research was carried out in the period 2
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39

Boyer, L., K. Baumstarck-Barrau, R. Belzeaux, et al. "Validation of a Professionals’ Satisfaction Questionnaire with Electronic Medical Records (PSQ-EMR) in Psychiatry." European Psychiatry 26, no. 2 (2010): 78–84. http://dx.doi.org/10.1016/j.eurpsy.2009.10.007.

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AbstractBackgroundElectronic medical records (EMR) are currently being implemented in psychiatric hospitals throughout Europe. The perceptions of health care professionals can contribute important information that may predict their acceptance of and desired mode of use for EMR, thus guiding EMR implementation.AimsTo develop a self-administered instrument designed to assess health care professionals’ satisfaction regarding EMR in a psychiatric hospital, based only on the professional point of view, according to the psychometric standards.MethodsThe development was supervised by a steering commi
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40

Bourgeois, Stacy, and Ulku Yaylacicegi. "Electronic Health Records." International Journal of Healthcare Information Systems and Informatics 5, no. 3 (2010): 1–13. http://dx.doi.org/10.4018/jhisi.2010070101.

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Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. This study investigates how EHR use, as implemented and utilized, impacts patient safety and quality performance. Data in this paper include nonfederal acute care hospitals in the state of Texas, and the data sources include the American Hospital Association, the Dallas Fort Worth Hospital Council, and the American Hospital Directory. The authors use partial least squares modeling to assess the relationship between hospital EHR use, patient safety, and quality of care. Patie
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41

Mant, Madeleine. "Children in the London: Inpatient Care in a Voluntary General Hospital." Medical History 62, no. 3 (2018): 295–313. http://dx.doi.org/10.1017/mdh.2018.24.

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The presence of children in English voluntary hospitals during the eighteenth century has only recently come under academic scrutiny. This research examines the surviving admission records of the London Hospital, which consistently record inpatient ages, to illuminate the hospital stays of infant and child patients and examine the morbidity of children during the long eighteenth century. Traumatic cases were the most common category of admission. The proportion of trauma cases admitted to the London Hospital was higher than in provincial English child patient cohorts, potentially reflecting th
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42

Maruster, Laura, Durk-Jouke van der Zee, Jaap Hatenboer, and Erik Buskens. "Tracing frequent users of regional care services using emergency medical services data: a networked approach." BMJ Open 10, no. 5 (2020): e036139. http://dx.doi.org/10.1136/bmjopen-2019-036139.

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ObjectivesThis study shows how a networked approach relying on ‘real-world’ emergency medical services (EMS) records might contribute to tracing frequent users of care services on a regional scale. Their tracing is considered of importance for policy-makers and clinicians, since they represent a considerable workload and use of scarce resources. While existing approaches for data collection on frequent users tend to limit scope to individual or associated care providers, the proposed approach exploits the role of EMS as the network’s ‘ferryman’ overseeing and recording patient calls made to an
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43

Schultz, Gwendolyn, and Majida Gaffar. "Retinopathy of Prematurity—Using Electronic Medical Records to Efficiently Follow Patients at Multiple Hospitals." Journal of Neonatology 35, no. 2 (2021): 54–58. http://dx.doi.org/10.1177/09732179211007600.

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Purpose: To report the use of a centralized electronic medical record (EMR) to provide timely retinopathy of prematurity (ROP) screening in a previously fragmented monitoring system in a standalone children’s hospital in Connecticut. Methods: A chart review of 306 visits for ROP screening in 3 neonatal intensive care units (NICUs) over a time period of 24 months. Results: All infants born at <30 weeks gestational age or birth weight <1,500g (N = 107) at these NICUs were screened for ROP according to the American Academy of Pediatrics guidelines. Data was collected before the implementati
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44

Tavares, Ricardo, Marcelo A. Ribeiro, Margarita Gonzalez, et al. "RECORDS OF IN-HOSPITAL CARDIOPULMONARY RESUSCITATION IN A MEDICAL CARDIOLOGIC ICU." Critical Care Medicine 33 (December 2005): A59. http://dx.doi.org/10.1097/00003246-200512002-00214.

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45

Aquino, M., J. M. Raboud, A. McGeer, et al. "Accuracy of Healthcare Worker Recall and Medical Record Review for Identifying Infectious Exposures to Hospitalized Patients." Infection Control & Hospital Epidemiology 27, no. 7 (2006): 722–28. http://dx.doi.org/10.1086/504355.

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Objective.To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting.Design.Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of
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46

Challen, Kirsty, and Darren Walter. "Physiological Scoring: An Aid to Emergency Medical Services Transport Decisions?" Prehospital and Disaster Medicine 25, no. 4 (2010): 320–23. http://dx.doi.org/10.1017/s1049023x00008268.

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AbstractIntroduction:Attendance at UK emergency departments is rising steadily despite the proliferation of alternative unscheduled care providers. Evidence is mixed on the willingness of emergency medical services (EMS) providers to decline to transport patients and the safety of incorporating such an option into EMS provision. Physiologically based Early Warning Scores are in use in many hospitals and emergency departments, but not yet have been proven to be of benefit in the prehospital arena.Hypothesis:The use of a physiological-social scoring system could safely identify patients calling
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47

Iskandar, Hary, Sabir Alwy, and Nurul Hudi. "KAJIAN YURIDIS PENGGUNAAN REKAM MEDIS UNTUK VERIFIKASI PEMBIAYAAN LAYANAN KESEHATAN." Medical Technology and Public Health Journal 2, no. 1 (2018): 35–41. http://dx.doi.org/10.33086/mtphj.v2i1.315.

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The use of patient medical records for hospital payment claims is in essence contrary to the medical records confidentiality rules. This study aims to review the judicial use of medical records in the verification of health care financing in the era of national health insurance. This research uses descriptive study method with normative juridical approach. Qualitative data comes from literature review such as primary, secondary and tertiary law. This study indicates that verifiers with the status of health workers have the legal authority to use patient information in medical records as they r
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48

Iskandar, Hary, Sabir Alwy, and Nurul Hudi. "KAJIAN YURIDIS PENGGUNAAN REKAM MEDIS UNTUK VERIFIKASI PEMBIAYAAN LAYANAN KESEHATAN." Medical Technology and Public Health Journal 2, no. 1 (2018): 35–41. http://dx.doi.org/10.33086/mtphj.v2i1.765.

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The use of patient medical records for hospital payment claims is in essence contrary to the medical records confidentiality rules. This study aims to review the judicial use of medical records in the verification of health care financing in the era of national health insurance. This research uses descriptive study method with normative juridical approach. Qualitative data comes from literature review such as primary, secondary and tertiary law. This study indicates that verifiers with the status of health workers have the legal authority to use patient information in medical records as they r
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49

Scott, Ian A., Clair Sullivan, and Andrew Staib. "Going digital: a checklist in preparing for hospital-wide electronic medical record implementation and digital transformation." Australian Health Review 43, no. 3 (2019): 302. http://dx.doi.org/10.1071/ah17153.

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Objective In an era of rapid digitisation of Australian hospitals, practical guidance is needed in how to successfully implement electronic medical records (EMRs) as both a technical innovation and a major transformative change in clinical care. The aim of the present study was to develop a checklist that clearly and comprehensively defines the steps that best prepare hospitals for EMR implementation and digital transformation. Methods The checklist was developed using a formal methodological framework comprised of: literature reviews of relevant issues; an interactive workshop involving a mul
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50

Swerissen, Hal. "Editorial: Strengthening clinical governance in primary health and community care." Australian Journal of Primary Health 11, no. 1 (2005): 2. http://dx.doi.org/10.1071/py05001.

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Large numbers of people die each year in hospitals as a result of preventable errors. High profile cases like the Royal Bristol Infirmary in the UK or the King Edward Memorial Hospital in Western Australia highlight the problem in the popular media, putting pressure on governments, providers and the professions to improve safety and quality in hospitals. In Australia, the Quality in Australian Health Care study reviewed the medical records of 14,179 admissions to 28 hospitals and found that an adverse event occurred in 16.6% of cases, with 51% considered to have been preventable (Wilson et al.
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