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The Pan African Medical Journal 2021the medical file is a key element of quality reflecting good hospital management. Many steps have been taken through its history leading up to computerization. This...
INTRODUCTION
the medical file is a key element of quality reflecting good hospital management. Many steps have been taken through its history leading up to computerization. This Process allows the sharing of files with both the health staff and patients, while respecting the professional confidentiality between parties. However, in Morocco, as is the case in other countries that are unable to computerize all their hospitals, it is necessary to study first the medical file in paper before proceeding with its computerization. The purpose of our study is to describe the state of the hard copy medical record in our Host University and international hospital, Cheikh Zaid in Morocco.
METHODS
that is a cross-sectional study that lasted for three months in Cheikh Zaid hospital. The collection of data from this institution was based on the evaluation of 100 medical records of inpatients, seeing as they respond to our study criteria and requirements better than outpatients. Said evaluation was inspired by a clinical audit grid recommended by the High Authority for Health (HAS). Extraction of the results is done using the SPSS 13.0, Microsoft Excel, and Microsoft Visio software. In addition, we used the observation method to correct the errors found.
RESULTS
the results showed that 75% of the files are in good condition and well organized. However, administrative documents were missing in 70% of the cases (national identity card, health insurance card and copy of the patient's consent form). Moreover, in 83% of cases, the identity of the person to be notified in case of complications and the consent form were missing. It is also the case for the discharge report. The latter is incomplete in 97% of the cases. Also, the file transfer data from one service to another were missing in 82% of the medical files.
CONCLUSION
according to the results, improving the medical file is necessary both administratively and medically. Thus, all parties, including doctors and nurses must be aware of their tasks and roles in this process. Despite the advances in the computerization of the medical file in several hospitals in Morocco, the maintenance of the hard copy version remains unavoidable and still necessary, to protect the rights of both the patient and his medical staff.
Topics: Cross-Sectional Studies; Hospital Administration; Hospitals; Humans; Medical Records; Medical Records Systems, Computerized; Morocco; Politics
PubMed: 33995760
DOI: 10.11604/pamj.2021.38.153.16330 -
International Journal of Environmental... Jun 2018An Electronic Medical Record (EMR) is a patient's database record that can be transmitted securely. There are a diversity of EMR systems for different medical units to...
An Electronic Medical Record (EMR) is a patient's database record that can be transmitted securely. There are a diversity of EMR systems for different medical units to choose from. The structure and value of these systems is the focus of this qualitative study, from a medical professional's standpoint, as well as its economic value and whether it should be shared between health organizations. The study took place in the natural setting of the medical units' environments. A purposive sample of 40 professionals in Greece and Oman, was interviewed. The study suggests that: (1) The demographics of the EMR should be divided in categories, not all of them accessible and/or visible by all; (2) The EMR system should follow an open architecture so that more categories and subcategories can be added as needed and following a possible business plan (ERD is suggested); (3) The EMR should be implemented gradually bearing in mind both medical and financial concerns; (4) Sharing should be a patient's decision as the owner of the record. Reaching a certain level of maturity of its implementation and utilization, it is useful to seek the professionals' assessment on the structure and value of such a system.
Topics: Attitude to Computers; Electronic Health Records; Greece; Health Personnel; Humans; Interviews as Topic; Oman; Qualitative Research
PubMed: 29857585
DOI: 10.3390/ijerph15061137 -
Mathematical Biosciences and... Apr 2023Structured information especially medical events extracted from electronic medical records has extremely practical application value and play a basic role in various...
Structured information especially medical events extracted from electronic medical records has extremely practical application value and play a basic role in various intelligent diagnosis and treatment systems. Fine-grained Chinese medical event detection is crucial in the process of structuring Chinese Electronic Medical Record (EMR). The current methods for detecting fine-grained Chinese medical events primarily rely on statistical machine learning and deep learning. However, they have two shortcomings: 1) they neglect to take into account the distribution characteristics of these fine-grained medical events. 2) they overlook the consistency in the distribution of medical events within each individual document. Therefore, this paper presents a fine-grained Chinese medical event detection method, which is based on event frequency distribution ratio and document consistency. To start with, a significant number of Chinese EMR texts are used to adapt the Chinese pre-training model BERT to the domain. Second, based on the fundamental features, the Event Frequency - Event Distribution Ratio (EF-DR) is devised to select distinct event information as supplementary features, taking into account the distribution of events within the EMR. Finally, using EMR document consistency within the model improves the outcome of event detection. Our experiments demonstrate that the proposed method significantly outperforms the baseline model.
Topics: Humans; Electronic Health Records; Machine Learning
PubMed: 37322971
DOI: 10.3934/mbe.2023489 -
The Journal of the Royal College of... Feb 1984
Topics: Family Practice; Humans; Medical Records; Medical Records, Problem-Oriented
PubMed: 6332194
DOI: No ID Found -
Journal of Infection and Public Health Jan 2021In order to meet the ever-increasing needs of health care, as well as helping patients who need continuous care after being discharged from the hospital and making...
In order to meet the ever-increasing needs of health care, as well as helping patients who need continuous care after being discharged from the hospital and making modern medical technology better serve humans, the design of electronic medical records for continuous care patients, especially those with malignant tumors, is investigated. In the research process, the idea of Browser/Server (B/S) framework is adopted, and the corresponding electronic medical record system is designed based on the targets and the overall structure of the system; afterward, the black-box testing and white-box testing are carried out to test the functions, reliability, and stability of the designed electronic medical record system; in addition, combined with other research results, the feasibility of the design is proved. It can be seen that the electronic medical record system designed for patients who need continuous care in the study is absolutely feasible, which can be further researched and improved with the development of electronic medical records; therefore, it would make greater contributions to both patients and hospitals in the future.
Topics: Delivery of Health Care; Electronic Health Records; Humans; Reproducibility of Results
PubMed: 31431422
DOI: 10.1016/j.jiph.2019.07.013 -
Journal of the American Heart... Apr 2022Background Electronic medical records are increasingly used to identify disease cohorts; however, computable phenotypes using electronic medical record data are often...
Background Electronic medical records are increasingly used to identify disease cohorts; however, computable phenotypes using electronic medical record data are often unable to distinguish between prevalent and incident cases. Methods and Results We identified all Olmsted County, Minnesota residents aged ≥18 with a first-ever diagnostic code for atrial fibrillation or atrial flutter from 2000 to 2014 (N=6177), and a random sample with an code from 2016 to 2018 (N=200). Trained nurse abstractors reviewed all medical records to validate the events and ascertain the date of onset (incidence date). Various algorithms based on number and types of codes (inpatient/outpatient), medications, and procedures were evaluated. Positive predictive value (PPV) and sensitivity of the algorithms were calculated. The lowest PPV was observed for 1 code (64.4%), and the highest PPV was observed for 2 codes (any type) >7 days apart but within 1 year (71.6%). Requiring either 1 inpatient or 2 outpatient codes separated by >7 days but within 1 year had the best balance between PPV (69.9%) and sensitivity (95.5%). PPVs were slightly higher using codes. Requiring an anticoagulant or antiarrhythmic prescription or electrical cardioversion in addition to diagnostic code(s) modestly improved the PPVs at the expense of large reductions in sensitivity. Conclusions We developed simple, exportable, computable phenotypes for atrial fibrillation using structured electronic medical record data. However, use of diagnostic codes to identify incident atrial fibrillation is prone to some misclassification. Further study is warranted to determine whether more complex phenotypes, including unstructured data sources or using machine learning techniques, may improve the accuracy of identifying incident atrial fibrillation.
Topics: Algorithms; Atrial Fibrillation; Electric Countershock; Electronic Health Records; Humans; International Classification of Diseases; Machine Learning; Medical Records
PubMed: 35348008
DOI: 10.1161/JAHA.121.023237 -
Annals of Epidemiology Nov 2016
Topics: Database Management Systems; Humans; Medical Record Linkage; Medical Records; Neoplasms; Pharmacoepidemiology; Prescription Drugs; Registries
PubMed: 27639347
DOI: 10.1016/j.annepidem.2016.08.015 -
Journal of the American Medical... 2010Under the provisions of the Health Information Technology for Economic & Clinical Health act providers need to demonstrate their 'meaningful use' of electronic health... (Review)
Review
Under the provisions of the Health Information Technology for Economic & Clinical Health act providers need to demonstrate their 'meaningful use' of electronic health record systems' health information exchange (HIE) capability. HIE usage is not a simple construct, but the choice of its measurement must attend to the users, context, and objectives of the system being examined. This review examined how usage is reported in the existing literature and also what conceptualizations of usage might best reflect the nature and objectives of HIE. While existing literature on HIE usage included a diverse set of measures, most were theoretically weak, did not attend to the interplay of measure, level of analysis and architectural strategy, and did not reflect how HIE usage affected the actual process of care. Attention to these issues will provide greater insight into the effects of previously inaccessible information on medical decision-making and the process of care.
Topics: Electronic Health Records; Health Services Research; Humans; Information Services; Medical Record Linkage; Medical Records Systems, Computerized; United States
PubMed: 20442148
DOI: 10.1136/jamia.2009.000471 -
Biomedical Journal 2015A medical record is an important source of information regarding medical care and medical record review plays an important role in the evaluation of the teaching... (Review)
Review
BACKGROUND
A medical record is an important source of information regarding medical care and medical record review plays an important role in the evaluation of the teaching proficiency. The study analyzed the difference between internal and external auditing when conducting medical record review for faculty promotion in a study institute.
METHODS
We analyzed the scores related to the medical records maintained by applicants for the faculty promotion of attending physicians during the period between 2008 and 2010 at the Chang Gung Memorial Hospital. The scores were obtained from one internal reviewer of the study institute and two external reviewers from other medical centers, and routine scores were obtained from the Committee of Medical Record 1 year before application. Pearson's correlation coefficient was used to analyze the correlation and statistical significance.
RESULTS
There were 259 applicants for faculty promotion enrolled in this study [professors (n = 33, 13%), associate professors (n = 63, 24%), assistant professors (n = 90, 35%), lecturers (n = 73, 28%)]. The scores of the external reviewers 1 and 2 were correlated with routine scores (r = 0.187, p = 0.002; r = 0.198, p = 0.001; N= 259), respectively. The correlation between external reviewers' average and ordinary scores was significant for assistant professor (r = 0.334, p = 0.001, n = 90) and professor grades (r = 0.469, p = 0.006, n = 33). However, the internal reviewer scores did not correlate with the routine scores (r = 0.073, p = 0.241, N = 259).
CONCLUSIONS
The scores from external reviewers correlated more with routine scores than the scores from internal reviewers, suggesting that utilizing an external auditing system of medical records for the faculty promotion of attending physicians is quite feasible and balanced.
Topics: Cohort Studies; Education, Professional; Faculty; Humans; Medical Records; Professional Competence; Teaching
PubMed: 25673167
DOI: 10.4103/2319-4170.151028 -
BMC Medical Education May 2021Medical students can enhance their knowledge by accessing patients' medical records and documenting patient care. This study assessed medical students' access to paper...
BACKGROUND
Medical students can enhance their knowledge by accessing patients' medical records and documenting patient care. This study assessed medical students' access to paper medical records and electronic health records (EHRs) in Saudi Arabia and compared students' experience of accessing paper medical records and EHR from their perspective.
METHODS
This cross-sectional study enrolled second-year to intern medical students randomly from different medical colleges in Saudi Arabia. A self-developed survey was administered to them. It comprised 28 items in three sections: general information about medical students and their level of accessing medical records, their experience with the medical record system used in hospitals, and their preference for the medical record type.
RESULTS
62.8% of participants had access to medical records, with 66.1% of them having access to EHRs and 83.27% had read-only access. The EHR group and paper group mostly liked being able to reach medical records effortlessly (70.1% and 67.1%, respectively). The EHR group had a better experience compared to the paper group with U = 5200, Mean Rank = 122.73, P = .04. Students who trained in University - owned and National Guard hospitals had better experiences compared to students who trained in other hospitals with Mean Ranks =122.35, and 147.99, respectively.
CONCLUSION
Incorporating EHR access into the medical curriculum is essential for creating new educational opportunities that are not otherwise available to medical students.
Topics: Cross-Sectional Studies; Curriculum; Electronic Health Records; Humans; Saudi Arabia; Students, Medical
PubMed: 33980207
DOI: 10.1186/s12909-021-02715-7