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Prehospital and Disaster Medicine Aug 2018IntroductionImproving medical record keeping is a key part of the World Health Organization's (WHO's; Geneva, Switzerland) drive to standardize and evaluate emergency...
UNLABELLED
IntroductionImproving medical record keeping is a key part of the World Health Organization's (WHO's; Geneva, Switzerland) drive to standardize and evaluate emergency medical team (EMT) response to sudden onset disasters (SODs).ProblemIn response to the WHO initiative, the UK EMT is redeveloping its medical record template in line with the WHO minimum dataset (MDS) for daily reporting. When changing a medical record, it is important to understand how well it functions before it is implemented.
METHODS
The redeveloped medical record was piloted at a UK EMT deployment course using simulated patients in order to examine ease of use by practitioners, and rates of data capture for key MDS variables.
RESULTS
Some parts of the form were consistently poorly filled in, and the way in which the form was completed suggested that the flow of the form did not align with the recorder's natural thought processes when under pressure.
CONCLUSION
Piloting of a single-sheet triplicate medical record during an EMT deployment simulation led to significant modifications to improve data capture and function.Jafar AJN, Fletcher RJ, Lecky F, Redmond AD. A pilot of a UK emergency medical team (EMT) medical record during a deployment training course. Prehosp Disaster Med. 2018;33(4):441-447.
Topics: Disasters; Emergency Medical Services; Humans; International Cooperation; Medical Records; Pilot Projects; United Kingdom
PubMed: 29962356
DOI: 10.1017/S1049023X18000468 -
British Journal of Nursing (Mark Allen...
Topics: Hospitals; Humans; Management Audit; Medical Records
PubMed: 7580091
DOI: 10.12968/bjon.1995.4.17.982 -
Journal of Clinical Computing 1988The literature gives evidence of a growing interest in the application of computer systems to medicine. It outline the performances, advantages, and benefits of these... (Review)
Review
The literature gives evidence of a growing interest in the application of computer systems to medicine. It outline the performances, advantages, and benefits of these systems, but often does not present the problems that arise in the design, realization, and introduction of such systems in health care organizations. This paper presents and analyzes some project-oriented and organizational problems, giving some possible solutions.
Topics: Abstracting and Indexing; Electronic Data Processing; Hospital Information Systems; Medical Records; Medical Records, Problem-Oriented
PubMed: 10302899
DOI: No ID Found -
British Medical Journal Mar 1959
Topics: Health Records, Personal; Humans; Medical Records; Patients
PubMed: 13629080
DOI: 10.1136/bmj.1.5122.640 -
The Mount Sinai Journal of Medicine,... Aug 2009Medical students have routinely documented patient encounters in both inpatient and outpatient care venues. This hands-on experience has provided a way for students to...
Medical students have routinely documented patient encounters in both inpatient and outpatient care venues. This hands-on experience has provided a way for students to reflect on patient encounters, learn proper documentation skills, and attain a sense of being actively involved in and responsible for the care of patients. Over the last several years, the practice of student note writing has come into question. Institutional disincentives to student documentation include insurance regulations that restrict student documentation from substantiating billing claims, concerns about the legal status of student notes, and implementation of electronic medical records that do not allow or restrict student access. The increased scrutiny of the medical record from pay-for-performance programs and other quality measures will likely add to the pressure to exclude students from writing notes. This trend in limiting medical student documentation may have wide-ranging consequences for student education, from delaying the learning of proper documentation skills to limiting training opportunities. This article reviews the educational value of student note writing, the factors that have made student documentation problematic, and the potential educational impact of limiting student documentation. In addition, it offers some suggestions for future research to guide policy in this area.
Topics: Curriculum; Documentation; Education, Medical, Undergraduate; Educational Measurement; Electronic Health Records; Humans; Liability, Legal; Medical Records; Medical Records Systems, Computerized; Students, Medical; Teaching; United States
PubMed: 19642157
DOI: 10.1002/msj.20130 -
The New Zealand Medical Journal Oct 2013The literature describes three categories of health records: the Official Medical Records held by healthcare providers, Personal Health Records owned by patients, and--a...
The literature describes three categories of health records: the Official Medical Records held by healthcare providers, Personal Health Records owned by patients, and--a possible in between case--the Shared Care Record. New complications and challenges arise with electronic storage of this latter class of record; for instance, an electronic shared care record may have multiple authors, which presents challenges regarding the roles and responsibilities for record-keeping. This article discusses the definitions and implementations of official medical records, personal health records and shared care records. We also consider the case of a New Zealand pilot of developing and implementing a shared care record in the National Shared Care Planning Programme. The nature and purpose of an official medical record remains the same whether in paper or electronic form. We maintain that a shared care record is an official medical record; it is not a personal health record that is owned and controlled by patients, although it is able to be viewed and interacted with by patients. A shared care record needs to meet the same criteria for medico-legal and ethical duties in the delivery of shared care as pertain to any official medical record.
Topics: Cooperative Behavior; Electronic Health Records; Health Records, Personal; Humans; Medical Record Linkage; New Zealand; Patient Participation; Pilot Projects
PubMed: 24162635
DOI: No ID Found -
Topics in Health Record Management Nov 1991Good record-keeping practices contribute to the high quality of the medical record. Is the medical staff actually aware of the multiple uses of the medical record today...
Good record-keeping practices contribute to the high quality of the medical record. Is the medical staff actually aware of the multiple uses of the medical record today as opposed to only a few years ago? This is all in keeping with multiple requirements for accreditation, state licensing requirements, hospital medical staff rules and regulations, and a more aggressive consumer. Physicians and attorneys alike depend on the documentation in the medical record to support their case. An independent detailed recollection of the case by caregivers without use of the medical record would be extremely difficult. Nothing can take the place of an accurate account of the patient's care in the medical record. Defense in the absence of supporting documentation would be very weak, if not lost. It is clear that inadequate or incomplete medical records expose the physician and the hospital to risk. Hospital rules and regulations should be strictly enforced to enhance patient care and to avoid potential legal action. If documentation problems are identified, utilize the medical staff committees for recommendations and action. Medical records are an integral part of patient care responsibility and should be treated as such. The medical record is a legal document that is the most reliable record of care rendered to the patient. In legal settings, the record will be scrutinized by expert witnesses for the plaintiff and the defense. What the records do not contain may be as important as what they do contain when there is an allegation that the patient's condition warranted intervention or action that was not taken.
Topics: Documentation; Forms and Records Control; Informed Consent; Medical Records; Medical Records Department, Hospital; Risk Management; Role; United States
PubMed: 10114765
DOI: No ID Found -
Critical Care Medicine 1975The problem-oriented approach to the medical record has aroused a long overdue interest in the structuring of the medical case file. Clinical information in the...
The problem-oriented approach to the medical record has aroused a long overdue interest in the structuring of the medical case file. Clinical information in the traditional record is source-structured and time-sequenced, whereas the problem-oriented system differs by being a problem-structured record retaining still a chronologic sequence. We have found that in acute illness the multiplicity of interacting pathophysiologic processes makes premature application of the problem-oriented approach cumbersome and unwieldy. The formulation of the problem list at an early stage often led to the reduplication of problems, creating disorder in the clinical picture rather than serving to clarify it. Some used the simple cataloguing of events and data as a substitute for clinical judgment and decision making, focusing more upon style rather than content of the medical record. By using a rigid physiologic system-structured "problem" list and a modification of the SOAP (Subjective Objective, Assessment, Plan) subdivision, we have improved the documentation of our intensive care patients. The summary of the patient's stay in the intensive care unit is structured with active and inactive problems, this summary to be further used as the permanent problem list.
Topics: Australia; Intensive Care Units; Medical Records; Medical Records, Problem-Oriented
PubMed: 1082409
DOI: 10.1097/00003246-197509000-00004 -
Academic Medicine : Journal of the... Jan 2005If patient-centered medicine is to become a widespread reality in academic medical centers, educational initiatives must include reform of the medical record. The...
If patient-centered medicine is to become a widespread reality in academic medical centers, educational initiatives must include reform of the medical record. The medical record is part of the hidden, or informal, curriculum of medical school and residency that defines for students and residents the essential ingredients of competent medical care. Whatever its merits, the conventional, problem-oriented medical record (POMR) is a pathology-oriented record that helps perpetuate a disease-focused, biomedical model of practice Patient-centered medicine requires a patient-centered medical record (PCMR), one that addresses the person and perspective of the patient as competently as it addresses the patient's disease. The author proposes a PCMR that includes a concise, upfront Patient Profile; speaks of "chief concerns," not "chief complaints"; makes Patient Perspective a captioned component of the History of Present Illness; replaces the POMR's formula SOAP (Subjective, Objective, Assessment, Plan) with HOAP (History, Observations, Assessment, Plan); includes important patient perspectives on the Problem List; and calls for additional, written attention to the person and perspective of the patient throughout the course of medical care Patient-centered records can guide and teach clinicians at every level of training and experience to practice patient-centered medicine. Moreover, such records can also provide measurable evidence that this teaching has been successful.
Topics: Education, Medical; Humans; Medical History Taking; Medical Records; Medical Records, Problem-Oriented; Patient-Centered Care
PubMed: 15618089
DOI: 10.1097/00001888-200501000-00009 -
Tidsskrift For Den Norske Laegeforening... Apr 2005
Topics: Diagnosis-Related Groups; Health Priorities; Humans; Medical Records
PubMed: 15815730
DOI: No ID Found