PubMed · 502026
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T Kanno. 1979. [Individual data control system].. https://pubmed.ncbi.nlm.nih.gov/502026/
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BACKGROUND: The following objectives were studied in the implementation of computerization in the registration of clinical histories: gather all the information obtainable from the patient, be able to up-date the information once introduced, use of the information by health care personnel, automatic carrying out of all routine reports, elaboration of hospital indexes, follow the conventional model of clinical history as much as possible and reasonable price. METHODS: The study was carried out in a 40-bed department of internal medicine in a county hospital. A mixed system of partial coding was used combined with free texts, the latter being with no limit of space. The clinical histories were structured in 9 groups which covered from personal data to complementary explorations. A personal computer compatible "AT" was employed. The program was designed and analyzed by internal medicine doctors using CLIPPER and language "C". RESULTS: The thousand one hundred histories were opened with the space occupied in the disc being of 7 Megabytes. Following the premise of: "write all data only once", the obtaining of all type of documents, indexes and listed was automatized facilitating the knowledge of the working of the department directly. Adaptation by medical personnel was good. CONCLUSIONS: The model presented achieved the previously mentioned aims of information gathering and up-dating, use of the information by hospital personnel, automatization of routine reports and indexes, the following of conventional models and economic feasibility. Computerization should not be imposed, must not represent more work and advantages should be obtained by its use.
This article identifies key areas of physician performance in nursing homes (NHs) cited by state regulators. Six faculty members of the University of Maryland Department of Family Medicine reviewed medical care in ten Maryland NHs, which constituted 6.7% of Maryland's Comprehensive-level beds, with a sample of 547 charts and 81 physicians. The reviewers recorded the absence of expected minimum standards of performance in patient care. Nine of the NHs had been cited and one was anticipating an audit by state regulators. Citation by regulators corresponded with inadequate documentation of patient history and physical examinations, especially of neurologic conditions; with inadequate health care maintenance; with mismanagement of laboratory findings such as bacteriuria; and with lack of medical administrative leadership and quality management. These key areas of physician performance should be regularly assessed or systematically changed in all NHs to maintain at least minimum standards of care.
Staff members from the University of Michigan Medical Center (UMMC), 1990 winner of the Commitment to Quality Award, describe how they integrated its quality assurance (QA) program into its total quality management (TQM) strategy. The QA program has changed in recent years to establish quality as a central priority, to educate staff in the importance of quality, and to disseminate information more effectively. While these initiatives were underway, UMMC began to embrace TQM as an operating philosophy. Recognizing both the strengths and weaknesses of QA, staff members have worked to apply TQM principles (eg, focus on processes) to QA while using the ongoing monitoring of QA to identify opportunities for improvement within the organization's TQM management system.