Q&A: Lack of Medical Records

2021 ◽  
Vol 26 (5) ◽  
pp. 17-19
Author(s):  
Christopher R. Brigham ◽  
Robert J. Barth
Keyword(s):  
2000 ◽  
Vol 5 (5) ◽  
pp. 4-5
Author(s):  
James B. Talmage ◽  
Leon H. Ensalada

Abstract Evaluators must understand the complex overall process that makes up an independent medical evaluation (IME), whether the purpose of the evaluation is to assess impairment or other care issues. Part 1 of this article provides an overview of the process, and Part 2 [in this issue] reviews the pre-evaluation process in detail. The IME process comprises three phases: pre-evaluation, evaluation, and postevaluation. Pre-evaluation begins when a client requests an IME and provides the physician with medical records and other information. The following steps occur at the time of an evaluation: 1) patient is greeted; arrival time is noted; 2) identity of the examinee is verified; 3) the evaluation process is explained and written informed consent is obtained; 4) questions or inventories are completed; 5) physician reviews radiographs or diagnostic studies; 6) physician records start time and interviews examinee; 7) physician may dictate the history in the presence of the examinee; 8) physician examines examinee with staff member in attendance, documenting negative, physical, and nonphysiologic findings; 9) physician concludes evaluation, records end time, and provides a satisfaction survey to examinee; 10) examinee returns satisfaction survey before departure. Postevaluation work includes preparing the IME report, which is best done immediately after the evaluation. To perfect the IME process, examiners can assess their current approach to IMEs, identify strengths and weaknesses, and consider what can be done to improve efficiency and quality.


2016 ◽  
Vol 22 ◽  
pp. 14
Author(s):  
Michelle Mocarski ◽  
Sandhya Mehta ◽  
Karin Gillespie ◽  
Tami Wisniewski ◽  
K.M. Venkat Narayan ◽  
...  

VASA ◽  
2017 ◽  
Vol 46 (6) ◽  
pp. 477-483
Author(s):  
Robert Karl Clemens ◽  
Frederic Baumann ◽  
Marc Husmann ◽  
Thomas Oleg Meier ◽  
Christoph Thalhammer ◽  
...  

Abstract. Background: Congenital venous malformations are frequently treated with sclerotherapy. Primary treatment goal is to control the often size-related symptoms. Functional impairment and aesthetical aspects as well as satisfaction have rarely been evaluated. Patients and methods: Medical records of patients who underwent sclerotherapy of spongiform venous malformations were reviewed and included in this retrospective study. The outcome of sclerotherapy as self-reported by patients was assessed in a 21 item questionnaire. Results: Questionnaires were sent to 166 patients with a total of 327 procedures. Seventy-seven patients (48 %) with a total of 159 procedures (50 %) responded to the survey. Fifty-seven percent of patients were male. The age ranged from 1 to 38.1 years with a median age of 16.4 years. The lower extremities were the most common treated area. Limitations caused by the venous malformation improved in the majority of patients (e.g. pain improvement 87 %, improvement of swelling 83 %) but also worsening of symptoms occurred in a minority of cases. Seventy-seven per cent would undergo sclerotherapy again. Conclusions: Sclerotherapy for treatment of venous malformations results in significant reduction of symptoms. Multiple treatments are often needed, but patients are willing to undergo them.


Crisis ◽  
2016 ◽  
Vol 37 (2) ◽  
pp. 155-160 ◽  
Author(s):  
Jin Kim ◽  
Han Joon Kim ◽  
Soo Hyun Kim ◽  
Sang Hoon Oh ◽  
Kyu Nam Park

Abstract. Background: Previous suicide attempts increase the risk of a completed suicide. However, a large proportion of patients with deliberate self-wrist cutting (DSWC) are often discharged without undergoing a psychiatric interview. Aims: The aims of this study were to investigate the differences in the characteristics and outcomes of patients with DSWC and those with deliberate self-poisoning (DSP) episodes. The results of this study may be used to improve the efficacy of treatment for DSWC patients. Method: We retrospectively reviewed the medical records of 598 patients with DSWC and DSP who were treated at the emergency department of Seoul Saint Mary's Hospital between 2008 and 2013. We assessed sociodemographic information, clinical variables, the reasons for the suicide attempts, and the severity of the suicide attempts. Results: A total of 141 (23.6%) patients were included in the DSWC group, and 457 (76.4%) were included in the DSP group. A significantly greater number of patients in the DSWC group had previously attempted suicide (p = .014). A total of 63 patients (44.7%) in the DSWC group and 409 patients (89.5%) in the DSP group underwent psychiatric interviews. Conclusion: More DSWC patients had previously attempted suicide, but fewer of them underwent psychiatric interviews compared with the DSP patients.


Crisis ◽  
2020 ◽  
Vol 41 (5) ◽  
pp. 367-374
Author(s):  
Sarah P. Carter ◽  
Brooke A. Ammerman ◽  
Heather M. Gebhardt ◽  
Jonathan Buchholz ◽  
Mark A. Reger

Abstract. Background: Concerns exist regarding the perceived risks of conducting suicide-focused research among an acutely distressed population. Aims: The current study assessed changes in participant distress before and after participation in a suicide-focused research study conducted on a psychiatric inpatient unit. Method: Participants included 37 veterans who were receiving treatment on a psychiatric inpatient unit and completed a survey-based research study focused on suicide-related behaviors and experiences. Results: Participants reported no significant changes in self-reported distress. The majority of participants reported unchanged or decreased distress. Reviews of electronic medical records revealed no behavioral dysregulation and minimal use of as-needed medications or changes in mood following participation. Limitations: The study's small sample size and veteran population may limit generalizability. Conclusion: Findings add to research conducted across a variety of settings (i.e., outpatient, online, laboratory), indicating that participating in suicide-focused research is not significantly associated with increased distress or suicide risk.


2014 ◽  
Author(s):  
C. McKenna ◽  
B. Gaines ◽  
C. Hatfield ◽  
S. Helman ◽  
L. Meyer ◽  
...  

2011 ◽  
Vol 41 (14) ◽  
pp. 62-63
Author(s):  
S.Y. TAN
Keyword(s):  

1970 ◽  
Vol 09 (03) ◽  
pp. 149-160 ◽  
Author(s):  
E. Van Brunt ◽  
L. S. Davis ◽  
J. F. Terdiman ◽  
S. Singer ◽  
E. Besag ◽  
...  

A pilot medical information system is being implemented and currently is providing services for limited categories of patient data. In one year, physicians’ diagnoses for 500,000 office visits, 300,000 drug prescriptions for outpatients, one million clinical laboratory tests, and 60,000 multiphasic screening examinations are being stored in and retrieved from integrated, direct access, patient computer medical records.This medical information system is a part of a long-term research and development program. Its major objective is the development of a multifacility computer-based system which will support eventually the medical data requirements of a population of one million persons and one thousand physicians. The strategy employed provides for modular development. The central system, the computer-stored medical records which are therein maintained, and a satellite pilot medical data system in one medical facility are described.


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