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Health Information Management : Journal... Jan 2020
Topics: Clinical Coding; Data Accuracy; Forms and Records Control; Humans; International Classification of Diseases; Medical Record Administrators; Medical Records; Professional Competence
PubMed: 31510815
DOI: 10.1177/1833358319874008 -
Proceedings : a Conference of the... 1996The problem oriented medical record (POMR) has proved to be very successful in providing a structure that helps doctors record their notes about patients, and view those...
The problem oriented medical record (POMR) has proved to be very successful in providing a structure that helps doctors record their notes about patients, and view those notes subsequently in a manner that quickly gives them a good understanding of that patients history. This approach has been validated by the American Institute of Medicine. With the increased use of computer systems that implement the POMR by doctors, the limitations of this structure have become apparent, and there is clearly scope for developing the model further to improve the quality of the data recorded, and adding meaning to it. This paper describes some of the limitations of the POMR, and discusses a number of areas in which it may be extended. Crucially, this is done in a manner which is both implementable, and usable. The extensions explored include some types of entity including encounters, episodes and subproblems; and an alternative view-the Timeline. The terminology used for the extensions is clarified. Mechanisms by which these extensions have been implemented are described. Ways in which systems can manage these extensions automatically are suggested. Such implementations are constrained by the need not to allow the demands of the computer to intrude into the patient encounter. They are also constrained by the requirements for reporting by professional and governmental institutions, and by what is pragmatically feasible in software and hardware.
Topics: Computer Systems; Medical Records Systems, Computerized; Medical Records, Problem-Oriented
PubMed: 8947709
DOI: No ID Found -
Medical Education Mar 1976
Topics: Clinical Competence; Diagnosis; Education, Medical; Humans; Medical History Taking; Medical Records; Medical Records, Problem-Oriented; Teaching
PubMed: 1083473
DOI: 10.1111/j.1365-2923.1976.tb00549.x -
The Journal of Family Practice Oct 1977The Problem-Oriented Record (POR) has had a profound effect upon the medical community. Since its introduction not quite ten years ago, POR has gained remarkable...
The Problem-Oriented Record (POR) has had a profound effect upon the medical community. Since its introduction not quite ten years ago, POR has gained remarkable acceptance. A short review of the relatively brief history of POR is given and various facets of its use are outlined as guidelines for more critical reappraisal of its merits. The fact, however, that POR is currently taught in a majority of medical schools and used in ever increasing numbers of hospitals is highly indicative of eventual conversion of all medical recoreds to POR format.
Topics: Diagnosis; Evaluation Studies as Topic; Hospital Records; Humans; Information Systems; Medical Records; Medical Records, Problem-Oriented; Primary Health Care
PubMed: 303278
DOI: No ID Found -
Scandinavian Journal of Primary Health... Sep 1984The "Balsfjord system" is a fully computerized system of medical records. The system is developed by the University of Tromsö in cooperation with the district...
The "Balsfjord system" is a fully computerized system of medical records. The system is developed by the University of Tromsö in cooperation with the district physicians in Balsfjord. It is designed for Norwegian general practice based on microcomputers. Each general practitioner has a computer terminal in his/her consulting room, and all the terminals can operate on the same file simultaneously. The main archive is a hard disc, in addition there is a a secondary diskette archive for old, out of date record versions. Each medical record is composed of seven components, where the medical information is logically organized. The system is able to print out prescriptions, sick-leave forms, and parts or the whole record. Included in the program are two statistical systems. One is based on data from encounters, and the other is a search and statistical system based on the individual record as the unit. The system has been very successful for the two and a half years it has been in use. Both the doctors and the ancilliary staff have appreciated the system in their daily work.
Topics: Computers; Data Display; Family Practice; Humans; Medical Records; Medical Records, Problem-Oriented; Microcomputers; Norway; Practice Management, Medical; Software
PubMed: 6336198
DOI: 10.3109/02813438409018087 -
Hospital Progress Oct 1973
Topics: Connecticut; Hospital Administration; Hospital Departments; Medical Records
PubMed: 4746782
DOI: No ID Found -
Australian Clinical Review 1992This article reports on an analysis of 109 hospitals that received recommendations for improvement within their Medical Record Service when surveyed by the Australian...
This article reports on an analysis of 109 hospitals that received recommendations for improvement within their Medical Record Service when surveyed by the Australian Council on Health Care Standards (ACHS) in 1990. Seventy-five per cent of Medical Record Service recommendations made at an earlier survey had been fully implemented and 17% partially implemented by hospitals at the time of their next survey in 1990. The major area receiving recommendations for improvement was medical record content. Other areas of concern were quality assurance, organization and administration, and space for research and work within the service. Certain aspects of medical record content also appeared to be resistant to change from one survey to the next.
Topics: Accreditation; Australia; Medical Records; Medical Records Department, Hospital; Quality Assurance, Health Care
PubMed: 1444935
DOI: No ID Found -
Medical Informatics = Medecine Et... 1988Computers have been introduced to many hospitals in Japan to enhance hospital administrative facilities and clinical laboratory. More recent introduction of computers,...
Computers have been introduced to many hospitals in Japan to enhance hospital administrative facilities and clinical laboratory. More recent introduction of computers, however, has aimed at improvement of the quality of medical services. So, it is highly important how to design and how to use the medical record database. The present status of medical record database systems in hospitals in Japan is described. From experience with the planning and use of the system at Fukui Medical School Hospital, the important points and problems in the design of database and file structure, and the ways to accumulate the code the data and their usage are discussed.
Topics: Disease; Hospital Information Systems; Japan; Medical Record Linkage; Medical Records; Quality Control
PubMed: 3386324
DOI: 10.3109/14639238809003573 -
Diabetes, Nutrition & Metabolism Apr 2001
Review
Topics: Humans; Medical Record Linkage; Medical Records Systems, Computerized; Practice Management, Medical; Quality of Health Care; Systems Integration
PubMed: 11383679
DOI: No ID Found -
Revue Medicale de La Suisse Romande Oct 1990
Topics: Continuity of Patient Care; Humans; Medical Records; Medical Records Systems, Computerized; Patient Care Planning
PubMed: 2244091
DOI: No ID Found