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At least 1,063 records · Page 59Linked to original sources
PubMed2006

Off the record.

UNLABELLED: Clinical dental records fulfil a variety of functions. Whilst there is no standard data set for dental records, it is essential that these are contemporaneous--that is, they are 'recorded at the time' A good written record should contain details of the patient's identification data, medical and dental history, clinical examination, diagnosis, treatment plan, reference to consent, and progress notes. This paper covers these aspects in detail, and provides information on how long records should be stored, and who may access clinical records. CLINICAL RELEVANCE: The recording of contemporaneous patient/treatment information is central to treatment planning and good patient care.

Dental Records↗
PubMed1978

Ownership and maintenance of dental records.

The maintenance of good dental records is essential for the defense of a professional liability claim. If a dentist must give records and radiographs to a patient, insurance carrier, or succeeding practitioner, he should always give copies and maintain the originals. As a professional liability claim can often be filed long after treatment ceases, the dentist should retain his records permanently. The right of a patient to gain access to his medical or dental records has been granted by recent court decisions as well as by laws and regulations enacted in some states. The court decisions granting a patient access to his records are law in the jurisdictions in which the cases were decided. However, those decisions would present persuasive authority in a stage having no case law or statute regarding access by the patient to medical or dental records. The dentist should consult his attorney to determine the local law before allowing a patient access to his records and radiographs.

Dental Records↗
PubMed2005

Potential impacts of patient access to their electronic care records.

This paper examines the interest and expectations of patients having access to their electronic care records. Semi-structured prospective interviews were performed with 109 patients in a community setting in London where all records are stored digitally either as coded data, free text or scanned in from the paper original. A booth had recently been set up for patients to access their electronic records in the waiting room with secure access through fingerprint recognition technology. The interviews detailed history and levels of interest in access, impact on relationship with clinician, familiarity with digital media and issues of security and accuracy. Patients were more interested in seeing their electronic than their paper record; they felt it would improve their relationship with their clinician; they generally trusted in the security of their records; they anticipated that there would be some mistakes; they were enthusiastic about the idea of adding to the record themselves, but were divided about having access over the internet. Patients are confident in and anticipate the value of having access to their electronic records.

Adolescent↗
PubMed2006

Sharing electronic health records: the patient view.

The introduction of a national electronic health record system to the National Health Service (NHS) has raised concerns about issues of data accuracy, security and confidentiality. The primary aim of this project was to identify the extent to which primary care patients will allow their local electronic record data to be shared on a national database. The secondary aim was to identify the extent of inaccuracies in the existing primary care records, which will be used to populate the new national Spine. Fifty consecutive attenders to one general practitioner were given a paper printout of their full primary care electronic health record. Participants were asked to highlight information which they would not want to be shared on the national electronic database of records, and information which they considered to be incorrect. There was a 62% response rate (31/50). Five of the 31 patients (16%) identified information that they would not want to be shared on the national record system. The items they identified related almost entirely to matters of pregnancy, contraception, sexual health and mental health. Ten respondents (32%) identified incorrect information in their records (some of these turned out to be correct on further investigation). The findings in relation to data sharing fit with the commonly held assumption that matters related to sensitive or embarrassing issues, which may affect how the patient will be treated by other individuals or institutions, are most likely to be censored by patients. Previous work on this has tended to ask hypothetical questions concerning data sharing rather than examine a real situation. A larger study of representative samples of patients in both primary and secondary care settings is needed to further investigate issues of data sharing and consent.

Adult↗
PubMed1999

[Quality of medical records as a basis for DRG classification in the health care system in Bosnia-Herzegovina].

Medical Record contains data about use of health care services of every member of certain population, no matter if they come from preventive or curative health care. Quality of Medical Records is very often in direct as well as indirect connection with health care quality. Better health care systems usually have better Medical Records. These are computer processed and stored on some of contemporary computer media, like: disks, microfilms, magnetic tapes and so-called "smart cards". Good Medical Record should have at least next characteristics: 1. Time dimension, which should contain chronological: past, present and future data, relevant to health care consumers. 2. It should be complete in a sense that every Medical Record must contain adequate medical and other relevant data for health care planning, organization and control. From the aspects of our research described here, it is very important that Medical Records contain all financial data. These usually are consequences of consumption of health care services from various resources of different levels. The results of our research about the application of DRG classification in B&H health system, that have been done in Tuzla University-Clinical Center, show that hospital Medical Records have many inadequacies, both in respect of medical as well as non-medical part. Physicians use very little ICD coding system. There is no uniform anamnesis, no detailed evidences about all hospital services, no adequately defined severity of disease and patient status at discharge. Due to manual based information system, there is no evidence about spending of resources per patient with financial data. The development and application of computer based health information system must go towards direction of solving these problems.

Bosnia and Herzegovina↗
PubMed2001

Dynamic viewer of medical events in electronic medical record.

Medical record should enable doctors to comprehend the patient's history and select suitable medical treatment. In paper based medical records, medical events (examination, treatment etc.) are recorded successively, and problem oriented recording is difficult to be applied to patients with much information and a long history. Consequently it is not easy to understand the patient's history from paper based medical records. In order to solve this problem, we developed the flow sheet system in our electronic medical record (EMR). To make a flow sheet, we analyzed the structure of the medical event data. In this paper we introduced the medical event information model for our EMR. Furthermore, we clarified the specification of the data presentation on the flow sheet. We developed the flow sheet on the basis of these analyses. Because there are 3 layers in the vertical axis of the flow sheet, many items of the medical event can be displayed on the screen. When user clicks the cell, the corresponding detail data including images are shown. This system functions to link medical event items with a problem, and shows the bundled items on the flow sheet when the user selects the problem. We implemented this system in Osaka University Hospital. The number of the types of medical events and those of detail events in inpatients are 5.0+1.7 (mean+SD) and 60+47, respectively. The medical doctors in Osaka University Hospital evaluated this system, and concludes that the flow sheet data presentation makes comprehension of the patient's history easier than paper based records. As to the function of bundling the items relevant to the problem, they feel it is especially useful for patients with chronic disease. Thus the flow sheet data presentation in EMR is useful for medical practice.

Chronic Disease↗
PubMed2003

A randomized controlled trial of a patient-accessible electronic medical record.

Legal and technologic trends are making medical records more patient-accessible. The Health Insurance Portability and Accountability Act (HIPAA) stipulates that "patients must be able to see and get copies of their records, and request amendments." Medical records are more commonly being stored in electronically, and methods have been developed to share these records with patients in a secure format.1,2 Previous studies of patient-accessible medical records generally only provided limited exposure to the medical record and lacked controls for bias and confounding.3 We performed a 12-month randomized controlled trial of a patient-accessible medical record to further assess the effects of such a program.

Health Status↗
PubMed2004

Access to electronic health records in primary care-a survey of patients' views.

BACKGROUND: The NHS is moving towards electronic access to health records for patients from 2004 and needs to involve patients in the development process. The aim of the study was to explore the views of a large sample of patients about online access to EPRs and health information in primary care. Areas covered included: accuracy rights of access; security; confidentiality and smart cards. MATERIAL/METHODS: The questionnaire was sent to 1050 patients selected at random from the practice list after stratification for age and sex. RESULTS: 66% of patients aged over 20 years old responded. Patients know they have the right to see their records although few have done so. Overall they feel the advantages of electronic health records outweigh the disadvantages. They have concerns about security, confidentiality, understanding their records, their accuracy and completeness. The patients recognised the potential benefits to their healthcare and relationships with health professionals. There was a majority view that parents / guardians and carers should have access to their dependants' records. CONCLUSIONS: Patients need to be confident that access is limited to those who have the right to see the records. The majority were confident they would understand their records and about half were familiar with computer use. However these are major issues for older patients who will require assistance in order to benefit from accessing their EPRs. It is essential that patient involvement takes place at every stage of the development of EPRs and that their views are taken into account.

Adult↗
PubMed2005

Medical records standards in selected countries and Iran: a comparative study.

Studies conducted in Iran showed that the absence of specific and applied standards relating to medical records, and the absence of a custodian organization, resulted in an incompatibility of medical records with standards and a deviation in the path of the activities of medical records departments from their main goals. Today's medical record professionals identified the development of a mechanism for establishing medical records standards as a reform priority. So, conducting a comparative study of related medical records standards in developed countries with Iran, is important in order to facilitate a nationwide standardization movement in Iran's medical record departments.

Australia↗
PubMed2006

[Disagreement between physicians' medication records and information given by patients].

INTRODUCTION: A survey was conducted to evaluate the level of disagreement between the drug records of family doctors and information provided by patients at the time of hospitalisation. MATERIALS AND METHODS: One hundred patients acutely admitted to a hospital department of medicine were consecutively included if the patient ingested more than two non-OTC drugs. A second drug interview was performed shortly after admission, and the patient's current medication was recorded. If no written medical record from the referring family doctor was available at the time of admission, the doctor was contacted by phone for supplementary information. Discrepancies between the information given by the patient and the medical records of family doctors were recorded. The results were analysed blindly by two of the authors (one senior and one junior doctor) to determine if the discrepancies were clinically relevant for the patient. RESULTS: We found at least one clinically relevant and potentially dangerous discrepancy in the medical records of 40% (95% CI 30%-50%) of the patients. In all, discrepancies were found in the drug lists of 63% of the patients. The patients with discrepancies were similar in age, sex, way of hospitalization and number of drugs ingested, compared to those without discrepancies. Afterwards the family doctors were invited to a meeting in which these problems were evaluated. CONCLUSION: We conclude that there is an urgent need for improvement in the communication between the primary and secondary health care sectors concerning medication being prescribed for patients with chronic diseases. The large number of discrepancies in the drug records of patients in this study is discouraging.

Adult↗
PubMed2005

Mother knows best: medical record management for patients with spina bifida during the transition from pediatric to adult care.

The personal health record has potential to improve health care transition for an emerging population of pediatric patients with complex chronic conditions who survive to adulthood. In this study qualitative techniques were used to assess how young adults with spina bifida and their parents interact with their medical records. Condensation and categorization strategies for inductive research based on Grounded Theory were used to analyze 1) Who is involved in record keeping 2) How the information is stored 3) What information is kept and shared among the different constituencies and 4) When patients and parents need the information. Theme analysis revealed that mothers play a central role in the medical record management of adolescents with spina bifida. The parent-maintained home based records served as a linking pin in a heterogeneous healthcare information environment. These records tended to be organized as time-lines. Parent and patients were concerned about how best to transition their health information management from parent to adult children. Patients and parents uniformly supported the idea of having access to the medical record on-line.

Adolescent↗
PubMed2006

Patient record access--the time has come.

There are now a number of systems across the world that enables patients to view their electronic health records. These include kiosks that have fingerprint authentication and also net-based access. The paper outlines the approach taken by the UK NHS explains the legal underpinning of access. Starting form the premise that record access is here to stay the paper outlines the research on benefits and risks of record access, concluding that, with simple precautions, record access is safe and affords many benefits to both patients and clinicians. It goes on to consider possible impacts of record access on the way records might be written as a co-produced document and emphasizes that national standards for record sharing need to be written.

Attitude to Computers↗
PubMed1991

Foundations for an electronic medical record.

Given the many efforts currently under way to develop standards for electronic medical records, it is important to step back and reexamine the fundamental principles which should underlie a model of the electronic medical record. This paper presents an analysis based on the experience in developing the PEN & PAD prototype clinical workstation. The fundamental contention is that the requirements for a medical record must be grounded in its use for patient care. The basic requirement is that it be a faithful record of what clinicians have heard, seen, thought, and done. The other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view. We use the criteria developed to re-examine Weed's Problem Oriented Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support.

Decision Making↗
PubMed1979

Medical records--legal perspectives.

Good documentation of medical diagnosis and treatment is not only a medical necessity, it is a legal one. Whether the physician is innocent or guilty of malpractice quickly becomes a side issue when it is discovered that he has tampered with the evidence, thereby attempting to perpetrate a fraud upon the court. And discovered it will be--the techniques are sophisticated and the motivation is high. Medical records are also important in workman's compensation cases, insurance claims, personal injury cases, and even in physician disciplinary hearings as well as their collection of bills. In creating and maintaining patient records, physicians and hospitals have several legal duties, including the duty to do so adequately, to safeguard the records' physical existence, and to prevent such use of the records as would violate the patient's right to confidentiality. Courts and legislatures are looking with increasing favor on the patient's interest in the content of his record, a phenomenon which is closely linked to the nationwide trend in favor of the patient's right to know and his right to determine his own physical destiny. For all these reasons, medical records no longer serve exclusively as the physician's private aid; medical records are increasingly becoming legal documents as well.

Confidentiality↗
PubMed1988

The anesthesia record.

The standard format of preoperative, perioperative, and postoperative patient anesthesia records, the categories of information included, and pharmacists use of this information are described. On the preoperative evaluation form, the anesthesiologist or anesthetist records information on the physical status of the patient and an overall impression of the anesthetic risk. The perioperative record is used for notation of the administration of anesthetic agents, fluids, blood products, and other medications and for recording vital signs, anesthetic and surgical interventions, and airway maintenance; this record shows a dynamic account of the patient's responses throughout the operation. Finally, the anesthesiologist notes postoperative problems related to anesthesia on the postoperative section of the record. The anesthesia record can be used by pharmacists for medication scheduling and therapeutic drug monitoring, assessment of fluid status, evaluation of hemodynamic response to drug and fluid interventions, quality assurance, and drug-use reviews.

Anesthesiology↗
PubMedDate not supplied

Dental record documentation in selected ambulatory care facilities.

Having recognized the differences in financial incentives between institutional providers and private practitioners participating in the Medicaid program, the New York State Health Department developed a streamlined mechanism of prior approval for 13 selected institutional providers of dental care. As part of the evaluation of this process, a retrospective audit of 316 dental records was conducted to assess the level of documentation present in the dental record. A followup audit was conducted 3 months after implementation of a plan to correct any deficiencies identified. More than 50 percent of the facilities were unable to present all the records requested at the time of the initial audit. Few of the audited records were free of deficiencies, and documentation of the results of the intra-oral examination was lacking in most facilities. The followup audit demonstrated statistically significant improvement in the level of record documentation. These results demonstrate that, even when good recordkeeping procedures were identified and agreed to by these institutional dental providers, performance was inadequate. However, the study also demonstrates that adequate records can be kept if sufficient incentives are provided. Efforts to evaluate retrospectively the delivery of dental care that are dependent on the dental record as a primary data source are unlikely to succeed unless incentives to encourage good recordkeeping are incorporated. Further research is needed to develop appropriate incentives that would operate in other practice settings.

Dental Clinics↗
PubMed1995

Can one patient record accommodate the diversity of specialized care?

Despite a quarter century of developments, few specialists directly use a computerized patient record, that fully replaces the paper chart. Because of the diversity of domains in specialized care, medical decision-making and the continuity of care may suffer from scattering of patient data over various records. The challenge was to develop a computerized patient record, that would be versatile enough to tailor it to specific needs, while keeping it uniform enough to permit physicians to share data on the same patient. In our CPR, the key that reconciles versatility with uniformity lies in the design of the data model. The CPR consists of a mother record with specialized sub-records, that all share the same data model. A physician can enlarge his scope for decision-making by consulting other specialized records on the same patient or by viewing the combined information of all sub-records without the need to convert data or to familiarize himself with different interfaces.

Humans↗
PubMed1995

Health record problem-oriented information system.

Health Record refers to the recording of the medical and relevant social history of the patient, obtained directly or indirectly. It is an instrument of frequent use that must guarantee the quality of assistance provided, reflecting all information pertinent to forming the patient's medical history. It must be designed so that data is easily and effectively retrieved for everyday use, without compromising the patient's privacy. The Health Record Problem Oriented model achieves all of these objectives. This model comprises: 1. Initial data: the relevant medical histories and biography is recorded. 2. Problems list: the patient provides reasons why she is seeking medical attention. 3. Performance plans: these include diagnostic, therapeutic, pharmacological, dietetic, physiotherapist, and surgical plans, as well as the education of the patient. 4. Evolution notes: the progress of the condition. This model guarantees multi-professional registration, an integral focus on the health, and a continued focus on the patient. These characteristics make it the model par excellence of Primary Care. Prior to the implementation of this model, existing information must be analyzed so that it can eventually be converted to a relational database. The Entity-Relationship Model (E/R Model) has been used to represent the database. Here, the basic concepts involved are entities, relationships, and attributes. Entities represent classes or objects from the real world that have common characteristics. The relationships represent the aggregation of two or more entities. The attributes are elemental properties of both entities and relationships. The E/R Diagram graphically represents the conceptual model of a database; the one built for the Health Record Problem Oriented reflects all the entities that compound the attending processes and the relationships existing between them. The Patient is the central axis of the attending process. The record contains the identifying data of the subject and his habits. We can know his medical history by means of his past Illness (personal and family record), Vaccine (what he is vaccinated against), and Case History (each patient has a case history). The other important component is the Consult Motive. A patient has a reason for every consultation, and this reason is added to her medical history as part of the Consult Motive. Each consult motive produces different events that are shown as relations with the other entities. So, for example, by analyzing a patient's history of complaints, a doctor can more suitably determine if she should recommend Cardiac or Anthropometric Exploration, request an Analysis, request a Radiography or Specialist Report, or prescribe a Treatment. The various elements that are part of a Consult Motive are expressed as different entities. Once the conceptual schema of the database is defined, the next step is to convert this schema to a logical schema, suitable for the Relational Model.

Medical Records Systems, Computerized↗