Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “MEDICAL RECORDS”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 19 recordsLinked to original sources
PubMedDate not supplied

Correlation of dental-record medical histories with outpatient medical records.

Medical history questionnaires and outpatient medical records of 115 patients were compared. All patients had a medical history of at least two years in both records. The dental records were initially reviewed, and patients' responses were compiled; when these were compared with the outpatient medical records, the overall discrepancy rate was > 86 percent. This overwhelming rate of error should make dentists aware that many routinely treated patients have medical conditions that are unknown to providers. Use of universal precautions, adequate medical-emergency training, and oral review of the dental health questionnaire are recommended.

Adult↗
PubMed2001

[Electronic medical records: medical and legal aspects, privacy, safety, and legal validity].

Medical records must collect all data concerning in-hospital management of patients: data have to be verified and easily retrievable. Clinicians are responsible for both format and content of medical records. Respect of patient's privacy must be made sure both during on-line management and long-term storage of records. Computerization can offer many advantages to clinicians, but needs some significant adjustments: training and motivation of operators, arrangement of clinical processes and of administrative rules to technological developments. Nevertheless, some important results can be afforded: standardization of procedures, distribution of univocal, verified and ubiquitous data to all concerned operators, protection against undesired retrieval, reliability of effective reports. Preliminary condition is a clinical local area network, widespread into the institution. Database implementation must follow well accepted methodology: flow chart design of data dictionary, standardization of data coding, input of verified data, effective reporting. Access to data must be controlled by sophisticated and sure password system. Back-up of data must be automatically available with adequate timing and methodology. Respect of rules on patient's privacy must be realized whenever possible. Complex clinical records should be made available, containing data, signals and images (both single frames and dynamic sequences), due to continuous technical progress of diagnostic tools. Medical records must be available for long periods of time: database engine and managing tools must be selected among well accepted and largely available producers; informatic assistance must be assured for management and evolution of systems over the years.

Computers↗
PubMed1976

Medical records, medical audit, and community hospitals.

A survey of community hospitals suggests a need for improving medical records and communications and introducing review procedures. A new and extended system based on an A4 size unit record is described. The benefits of a medical audit procedure in which all general practitioners and senior nurses participate are discussed.

Communication↗
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↗
PubMed1989

The misinformation era: the fall of the medical record.

Medical record information has become less reliable than ever before despite the electronic information revolution in medical care and the authority medical records have been accorded in our society. Long flawed by errors introduced by medical personnel, patients, and machines, medical records have had a further decline in credibility as a result of the loss of confidentiality and the imposition of well-meaning but unrealistic cost-control regulations on medical practice. Medical records are being distorted and fashioned to keep clinically important but sensitive personal information about patients from public view. To comply with standards of care and a reimbursement system blind to biologic diversity, medical records are being forced to address only the technical side of care. Until these deficiencies are corrected, our increasing dependence on medical records should be balanced by increasing skepticism about the value of the information they contain.

Confidentiality↗
PubMed2001

The CRABEL score--a method for auditing medical records.

Medical record keeping has become increasingly important particularly for research, audit and medico-legal purposes. The authors present a protocol, the CRABEL score, that is quick and easy to use for the assessment of the quality of medical record keeping with the purpose of standardizing the audit of medical records and improving their quality.

Clinical Protocols↗
PubMed1981

Physician-patient agreement about depression: notation in medical records.

Medical patients were prescreened for depression; their physicians were given the results of the screening to see if such intervention altered the frequency of the physicians' appropriate notations about depression in the medical record. As part of this study, physicians' and patients' global ratings of patient depression were examined in relation to Zung Self Rating Depression Scales (SDS) Scores and medical record notation. On their initial encounter in a University General Internal Medicine Clinic, physicians and patients were in close agreement about the extent to which patients felt sad or blue, and these global ratings correlated significantly with patients' self-reports on the SDS. In general, physicians tended to rate patients as more depressed than patients rated themselves. However, although medical record notations about depression were highly correlated with patient and physician global ratings of mood and with SDS scores, notations about depression appeared in only about 70% of charts where the physician assessed the patient's mood as being significantly depressed.

California↗
PubMed2000

Finance, pharmaceuticals, providers issue brief: medical records.

Medical records confidentiality has blossomed into one of the bigger state and federal topics of the 2000 legislative session. The issue has evolved to encompass regulation of the access to records aspect of health privacy, rather than 1999's stressing the importance of records privacy altogether. This shift is placing more emphasis on "who" (insurers, corporations, researchers, etc.) gets right of entry to sensitive and personally revealing medical records, as opposed to "what" (which file types will be private, which will not).

Confidentiality↗
PubMed2002

Cognitive analyses of a paper medical record and electronic medical record on the documentation of two nursing tasks: patient education and adherence assessment of insulin administration.

The incorporation of electronic medical records into busy physician clinics has been a major development in the healthcare industry over the past decade. Documentation of key nursing activities, especially when interacting with patients who have chronic diseases, is often lacking or missing from the paper medical record. A case study of a patient with diabetes mellitus was created. Well established methods for the assessment of usability in the areas of human-computer interaction and computer supported cooperative work were employed to compare the nursing documentation of two tasks in a commercially available electronic medical record (eRecord) and in a paper medical record. Overall, the eRecord was found to improve the timeliness and quality of nursing documentation. With certain tasks, the number of steps to accomplish the same task was higher, which may result in the perception by the end user that the tool is more complex and therefore difficult to use. Recommendations for the eRecord were made to expand the documentation of patient teaching and adherence assessment and to incorporate web technology for patient access to medical records and healthcare information.

Ambulatory Care Facilities↗
PubMed1982

Giving patients a copy of their computer medical record.

Medical summaries were prepared by a general practitioner for inclusion in a computer system. Both the medical records and a patient-filled questionnaire were used. A representative sample of the practice population were then sent their summaries. In creating the summaries the general practitioner felt the need to exclude 11 diagnoses whenever they appeared (5 per cent of the patients), and to suppress one or more diagnoses in a further 14 per cent of patients. In 2 per cent of summaries the general practitioner felt unable to give a copy to the patient because he was afraid of an adverse reaction by the patient or immediate relatives.The patients' views of the usefulness of the summaries, and of their accuracy and completeness, were sought by a questionnaire. Replies were received from 71 per cent; of these, 91 per cent reported that they thought the summary useful. However, in 18 per cent of cases, the patients requested additions, corrections or deletions. Only 1 per cent of patients replied that they definitely did not like the idea of a computer containing their medical information.Some of the benefits and difficulties both of using a computer to store medical information, and of giving the patient a copy of the medical summary, are discussed.

Computers↗
PubMedDate not supplied

Standards for medical identifiers, codes, and messages needed to create an efficient computer-stored medical record. American Medical Informatics Association.

A major obstacle to establishing a computer-stored medical record is the lack of "standards" that would permit government, care providers, insurance companies, and medical computer system developers to share patient data easily. In this position paper, the Board of Directors of the American Medical Informatics Association recommends specific approaches to standardization in the areas of patient, provider, and site of care identifiers; computerized health care message exchange; medical record content and structure, and medical codes and terminologies. The key concept developed in this position paper is that developers and users of computer-stored medical records must embrace existing and tested approaches, despite their imperfections, to progress quickly. This approach to standardization is being coordinated with the American National Standards Institute's Health Informatics Standards Planning Panel. The development of standards is a long-term process involving continued refinement. The proposed standards are an important step toward the goal of better and more efficient health care.

Association↗
PubMed1997

The search for the elusive electronic medical record system--medical liability, the missing factor.

Over the past few years, the traditional paper-based medical record system has come under close scrutiny by every participant in the healthcare industry. Some groups, especially federal agencies such as Medicare and Medicaid, HMOs, and other third party payors, have begun to demand changes in medical record documentation, and have become very assertive as to what goals and objectives will be met. In contrast, the medical liability insurance industry has remained almost invisible during this period of transition. At a recent electronic medical records (EMR) conference participants attending a software development workshop were asked if they had their systems reviewed from a medicolegal standpoint by a malpractice insurance carrier. In response to this inquiry, not one software vendor raised their hand to indicate this had been accomplished, or was even contemplated. In the author's opinion, the key missing factor in the current quest for a paperless medical office system rests in the domain of those who represent the medical liability industry. All of these gate-keepers of medical loss and risk prevention will eventually be called upon, either by choice or necessity, to validate every working EMR system that is used in medical practices in the future. This article will explore the best information published from this currently silent sector of the industry, and proposes an active involvement by the medical liability industry in the current EMR design and development processes taking place. In addition, there are 10 minimum EMR design criteria contained in this article that are recommended for implementation based upon 16 years of medical malpractice experience and loss prevention input.

Humans↗
PubMed1986

Report of the Task Force on Medical Record Education. American Medical Record Association.

An eight-member task force on medical record education was created in 1985 as part of AMRA's strategic planning process and long history of commitment to education. This report on their activities was presented to the Board of Directors in September 1986. While not intended to be a definitive work plan, the recommendations in the report involve the entire AMRA membership. The task force expects and encourages extensive debate on the issues and recommendations contained herein.

Accreditation↗