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Results for “computerized medical records systems”

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At least 19 recordsLinked to original sources
PubMedDate not supplied

Tracking medical students' clinical experiences with a computerized medical records system.

A fully computerized system for recording and reporting of medical students' patient contacts has been developed and successfully used in a high-volume outpatient practice. In contrast to previously described systems, the need for manual recording and/or entry of patient data has been eliminated by the use of an existing, integrated computerized medical records system. This makes possible the generation of frequent reports and timely review and adjustment of student experiences. The system has broad applicability and may also be useful for research in medical education.

Clinical Clerkship↗
PubMed1979

The computerized medical record system: meeting the challenge for nursing.

A system of computerized medical record-keeping in a health maintenance organization is described. Some problems arising in the shift from manual to computerized record-keeping are discussed. Perhaps the most important for nursing is the increase in the nursing staff's responsibility for complete, consistent documentation of patient care concomitant with the shift to a computerized system. Nurses must be comfortable with patient assessment, patient management and documentation in order to utilize the system effectively.

Computers↗
PubMed1983

Cost-benefit analysis of a computerized medical record system.

This paper describes the cost-benefit analysis of a computerized medical record system for use in physicians' offices. Actual data for savings in physician time in paper work was collected. The qualitative benefits of the system were evaluated using a questionnaire. The cost-benefit ratios demonstrated that the use of a computerized medical system is justified.

Ambulatory Care Facilities↗
PubMed1987

A microcomputer-based computerized medical record system for a general practice teaching clinic.

A low-cost and user-friendly computerized medical record system that includes patient demographic data, family genogram and social information, problem list, medication list and repeat prescription, progress notes, and laboratory data has been developed for a general practice teaching clinic. The system also has an automated health maintenance and disease management package, a number of research report programs, and a basic accounting package. The computerized medical record system has provided a very valuable tool for improving patient care, teaching, and general practice research. A standard software package has been developed for other small to medium-sized practices to use without having to redevelop their own software.

Computers↗
PubMed1993

Patients' reactions to physician use of a computerized medical record system during clinical encounters.

BACKGROUND: As physicians begin to use computer technology in front of patients during clinical encounters, concern has been raised that such computer use may exert a dehumanizing effect on the physician-patient relationship. To investigate this concern, we measured patient reactions to physician use of a computerized medical record system during clinical encounters. METHODS: Adult patients who presented for clinical care were randomized into three groups. With the first group, the physician used a standard paper-and-pencil charting system during the encounter. With the second group, the physician used a computerized medical record system with keyboard input. With the third group, the physician used the computerized medical record system with voice input. Patient reactions were measured with a questionnaire that the patients completed after the clinical encounter. RESULTS: For most components of the physician-patient relationship studied in this report, questionnaire scores did not differ significantly among the three study groups. Patients in the voice input group rated physician explanations of patient problems significantly higher than patients in the other two groups. There was a trend for patient confidence in the physician to be higher in the keyboard input group. Although measured encounter durations were significantly shorter in the computer groups, there were no differences in patient satisfaction with encounter duration among the three groups. CONCLUSIONS: Physician use of computers during clinical encounters was not associated with a decline in the perceived quality of the physician-patient relationship.

Adult↗
PubMed1994

Physician use of a computerized medical record system during the patient encounter: a descriptive study.

The computerized medical record program, CLINIC, specifically designed at Ben-Gurion University of the Negev to be used on-line in a primary care clinic during a patient encounter by healthcare professionals, has been in use for over 6 years in two community clinics. In order to analyse the effectiveness and use of CLINIC, four physicians were video recorded during working sessions before and after the introduction of CLINIC. While using CLINIC did not change the total mean encounter time, the lengths of the encounter components and record use did change. The physicians' work style changed from a 'conversational pattern' (continuous data recording) to a 'blocked pattern' (data entry at intervals).

Attitude of Health Personnel↗
PubMed2002

Development of an assessment tool to measure the influence of clinical software on the delivery of high quality consultations. A study comparing two computerized medical record systems in a nurse run heart clinic in a general practice setting.

A rating scale was developed to assess the contribution made by computer software towards the delivery of a quality consultation, with the purpose of informing the development of the next generation of systems. Two software programmes were compared, using this scale to test their ability to enable or inhibit the delivery of an ideal consultation with a patient with heart disease. The context was a general practice based, nurse run clinic for the secondary prevention of heart disease. One of the programmes was customized for this purpose; the other was a standard general practice programme. Consultations were video-recorded, and then assessed by an expert panel using the new assessment tool. Both software programmes were oriented towards the implementation of the evidence, rather than facilitating patient-centred practice. The rating scale showed, not surprisingly, significantly greater support from the customized software in the consultation in five out of eight areas. However, the scale's reliability measured by Cronbach's Alpha, was sub-optimal. With further refinement, this rating scale may become a useful tool that will inform software developers of the effectiveness of their programmes in the consultation, and suggest where they need development.

Ambulatory Care↗
PubMed1988

Assessing the quality of data entry in a computerized medical records system.

A primary care university clinic discovered major errors in its medical records after instituting a computerized medical records system. A quality assessment tool was devised to measure the error rate and provide clues to the sources of these errors. During the implementation of this tool a marked reduction in data entry errors occurred suggesting its use had a positive impact on our medical record quality.

Arizona↗
PubMed1999

Design elements for a computerized patient record.

Computerized medical record systems have to present user- and problem-oriented views of a patient record to health-care professionals. Presentation and manipulation of data must be easily adaptable to current and future demands of medical specialties and specific settings. During the definition, development and evaluation of a prototype of a computerized patient record system, design elements were elaborated to support physicians and other health-care professionals. Our approach shows a high degree of flexibility and adaptability to specific needs, problem orientation and connectivity to other systems, via a hospital information network. The explicit description of the contents of a patient record allows to augment the number of items that can be recorded without modifying the data structure. New views on patient data can be added to the system without interfering with the routine use of the system. Application in several medical specialties proved the feasibility of our prototype.

Medical Records Systems, Computerized↗
PubMedDate not supplied

Errors in a computerized medical records system (CLINICS).

The accuracy of computer-held medical information can be of critical importance in patient care, therefore it is important not only to know the error rate in the stored data but also to know the effectiveness of error checking and correction programs. This paper reports on the errors which were detected by checking the consistency between stored data and incoming data (context checks), in Southampton University Primary Medical Care computer system (CLINICS). The majority of detected errors were traced either to the registration of new patients or to the doctors failing to pay adequate attention to detail in their record keeping (or to their legibility). 7% of incoming data had errors detected by the context checking program and subsequently corrected; we calculate that the stored data contains less than 1% in error.

Computers↗
PubMed2001

The emergency medicine department system: a study of the effects of computerization on the quality of medical records.

A template based computerized medical record system known as the Emergency Medicine Department System (EMDS) was installed in the emergency department of the National University Hospital, Singapore, replacing handwritten records. A study was carried out to show how the implementation of the EMDS improved the quality of medical records. A retrospective review of old manual records and the ones generated by the EMDS was done by means of a scoring system. The raw scores represent the amount of information captured. The calculated means of scores were then used to compare the records. It was found that EMDS improves the quantity of data capture over the old records in all sections compared. This was seen regardless of the experience of the user. The use of a non-structured generic template results in less data captured compared with a structured symptom-specific template. The design of questions has a great influence in that a double-choice question captures more data than single-choice questions. Building in 'locking' or enforcement mechanisms in the EMDS also helped achieve almost full capture of critical information, such as examination time.

Chest Pain↗
PubMed1995

Applying a controlled medical terminology to a distributed, production clinical information system.

To maximize the value of computerized medical records systems, an organizing structure is needed. That structure can be provided by a controlled medical terminology (CMT). At Columbia-Presbyterian Medical Center, we have been employing a controlled medical terminology, our Medical Entities Dictionary (MED), to mediate the storage and retrieval of patient data and enable decision support applications. This paper describes how the MED is actually used for data management in our distributed clinical information systems environment. Our system tools which access the MED for production purposes facilitate the mapping of terms from many sources to a uniform representation of concepts and also return information about the relationships between concepts. Applications which access a CMT for production purposes should be optimized for performance in high volume settings, fault tolerant, synchronizable, extensible, portable, and maintainable. We briefly describe our system architecture and then demonstrate how we utilize the MED for translation and semantic information as data is moved into and out of our patient database. We discuss our current tools and present a preview of the next generation of applications which will manage access to the MED for our production systems.

Computer Communication Networks↗