Towards a Structured Electronic Patient Record for Supporting Clinical Decision-Making

2014 ◽  
pp. 297-306 ◽  
Author(s):  
Bente Christensen ◽  
Gunnar Ellingsen
Keyword(s):  
Decision Making ◽  
Electronic Patient Record ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Patient Record

SP10.2.12 Information Sustainability: The revitalisation and upcycling of 373,342 historic surgical pathology records into the contemporary electronic patient record in one UK NHS Hospital Trust

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Fatima Rahman ◽  
Alan Hales ◽  
David Cable ◽  
Keith Burrill ◽  
Adrian Bateman ◽  
...  
Keyword(s):  
Electronic Patient Record ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Patient Record ◽  
Clinical Use ◽  
Data Resource ◽  
Cancer Data ◽  
Transition Points ◽  
Pathology Reports ◽  
Cellular Pathology

Abstract Aims Surgical and Cellular pathology (‘e-pathology’) record sets are a valuable data resource with which to populate the Electronic Patient Record (EPR). Accessible reports, even decades old, can be of great value in contemporary clinical decision making and as a resource for longitudinal clinical research. They commonly identify the operation, the location and the pathology, even if not to modern reporting standards. Methods Since 2010, we have built and implemented a timeline structured EPR for the ‘whole-of-life’ visualisation of the electronic documents (e-Docs) of 2.5M+ patients on our Master Index. Prior to this project, our earliest e-Docs dated to 1995. We tracked down 373,342 inert e-pathology reports from our legacy Ferranti (1990-1997) and Masterlab (1997-2004) systems. These were uploaded into our active file servers, following appropriate data quality and patient identity reconciliation checks. Results We have progressively restored 373,342 previously inaccessible e-pathology records to clinical use and to immediacy of access, and in the process extending our “addressable EPR” back to 1990 for living and deceased patients. This process has also allowed us to populate and validate an EPR-integral breast cancer data system of 20,000 cases with e-pathology records dating back to 1990. Conclusions The sustainable revitalisation of old e-pathology reports into a timeline structured EPR creates preserves and upcycles the investment in pathology reporting which is otherwise progressively lost to clinical use. E-pathology records provide reliable, life-long evidence of critical transition points in individual lives and disease progression for clinical and research use, when they can be instantly accessed.

Clinical Decision Making and Oral Motor Treatments

ASHA Leader ◽  
2005 ◽  
Vol 10 (8) ◽  
pp. 8-35 ◽  
Author(s):  
Heather M. Clark
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Oral Motor

Debates in Dysphagia Management: How Do You Use Evidence-Based Practice in Your Dysphagia Patient Care?

2011 ◽  
Vol 20 (4) ◽  
pp. 121-123
Author(s):  
Jeri A. Logemann
Keyword(s):  
Decision Making ◽  
Patient Care ◽  
Clinical Outcomes ◽  
Clinical Judgment ◽  
Clinical Decision Making ◽  
Evidence Based Practice ◽  
Clinical Decision ◽  
Evidence Based ◽  
Clinical Method ◽  
Do So

Evidence-based practice requires astute clinicians to blend our best clinical judgment with the best available external evidence and the patient's own values and expectations. Sometimes, we value one more than another during clinical decision-making, though it is never wise to do so, and sometimes other factors that we are unaware of produce unanticipated clinical outcomes. Sometimes, we feel very strongly about one clinical method or another, and hopefully that belief is founded in evidence. Some beliefs, however, are not founded in evidence. The sound use of evidence is the best way to navigate the debates within our field of practice.

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