Use of data from a hospital online medical records system by physicians during preanesthetic evaluation

1996 ◽  
Vol 12 (5) ◽  
pp. 405-408 ◽  
Author(s):  
Gordon L. Gibby ◽  
Guido Lemeer ◽  
Keith Jackson
Keyword(s):  
Medical Records ◽  
Use Of Data ◽  
Medical Records System ◽  
Preanesthetic Evaluation

Monitoring, Evaluation, Disease Surveillance, and Quality Improvement

2017 ◽  
Author(s):  
Joia S. Mukherjee
Keyword(s):  
Quality Improvement ◽  
Medical Records ◽  
Disease Surveillance ◽  
Program Planning ◽  
Health Data ◽  
Quality Data ◽  
Electronic Systems ◽  
Health Delivery ◽  
Use Of Data ◽  
Improve Health

Quality data are necessary to make good decisions in health delivery for both individuals and populations. Data can be used to improve care and achieve equity. However, systems for health data management were historically weak in most impoverished countries. Health data are not uncommonly compiled in stacks of poorly organized paper records. Efforts to streamline and improve health information discussed in this chapter include patient-held booklets, demographic health surveys, and the use of common indicators. This chapter also focuses on the evolution of medical records, including electronic systems. The use of data for monitoring, evaluation, and quality improvement is explained. Finally, this chapter reviews the use of frameworks—such as logic models and log frames—for program planning, evaluation, and improvement.

scholarly journals 530 An Audit of Appropriate Documentation Following Urethral Catheterisation

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
I Dokubo ◽  
J Armitage
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Clinical Care ◽  
Medical Personnel ◽  
Urethral Catheter ◽  
Residual Volume ◽  
Urethral Catheterisation ◽  
Catheter Size ◽  
Medical Records System ◽  
Insertion Process

Abstract Introduction Urethral catheterisation is a procedure frequently done in the hospital by medical personnel. Appropriate documentation is necessary to ensure safe clinical care and to reduce the risk of litigation. Method We randomly reviewed electronic notes of patients seen by the on-call urology team who had a urethral catheter inserted in September 2020. Reviewing the trust’s guidelines, we considered that appropriate documentation should include reference to the following 10 items; indication, chaperone present, consent obtained, groin examination, catheter size, catheter type, insertion process, urine colour, water in balloon and residual volume were reviewed. Results A total of 50 patients were included. 72%(36/50) were inserted by a member of the urology team. Only 28%(14/50) had all 10 items documented. Indication for catheterisation was best documented at 94%(47/50) while presence of a chaperone and groin examination (i.e. presence of a foreskin and its replacement post-catheterisation) were the lowest at 44%(22/50). Conclusions This study shows there is low compliance to adequate documentation of urethral catheterisation. A ‘smart phrase’ has been developed for use with our Trusts electronic medical records system to assist clinicians with appropriate documentation. Clinicians that use the phrase ‘.icat’ are prompted to document all 10 requisite items. This uses the mnemonic i-CATHETAR [indication, Chaperone and consent, groin Assessment, Tube (catheter size and type), insertion process (Hard/Easy), urine Tint, Aqua in balloon, Residual volume]. A second audit cycle is currently being done to review the effectiveness of this intervention.

Errors in a Computerized Medical Records System (CLINICS)

1979 ◽  
Vol 4 (4) ◽  
pp. 203-208 ◽  
Author(s):  
A. Basden ◽  
E. M. Clark
Keyword(s):  
Medical Records ◽  
Computerized Medical Records ◽  
Medical Records System

A study of the use of free-text fields within a computer medical records system

1985 ◽  
Vol 17 (2) ◽  
pp. 155-170 ◽  
Author(s):  
A.R. Evans ◽  
P.J. Absolon ◽  
G. Kaye ◽  
P.A. Snow
Keyword(s):  
Medical Records ◽  
Free Text ◽  
Medical Records System

scholarly journals Factors affecting the utilisation of electronic medical records system in Malawian central hospitals

2017 ◽  
Vol 29 (3) ◽  
pp. 247 ◽  
Author(s):  
Khwima E. Mkalira Msiska ◽  
Andrew Kumitawa ◽  
Benjamin Kumwenda
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Factors Affecting ◽  
Medical Records System

Drugs that can cause respiratory depression with concomitant use of opioids

2017 ◽  
Vol 16 (1) ◽  
pp. 186-186
Author(s):  
B.D. Sigmarsdottir ◽  
Th.K. Gudmundsdottir ◽  
S. Zoäga ◽  
P.S. Gunnarsson
Keyword(s):  
Respiratory Depression ◽  
Medical Records ◽  
Medical Condition ◽  
University Hospital ◽  
Drug Classes ◽  
Threatening Condition ◽  
Life Threatening ◽  
Using Data ◽  
Medical Records System ◽  
Sedative Drugs

Abstract Aims Respiratory depression is a serious life threatening condition and a known adverse event of opioids. Little is known about the use of the opioid antidote naloxon in Iceland, and the additive effects of other potentially respiratory depressive drugs administered with opioids. The aim of the study was to review the literature on drugs that may cause respiratory depression and to assess medication use in patients receiving parenteral naloxone in Landspítali University Hospital. Methods A review and analysis of drugs that can cause respiratory depression based on information from the scientific literature, medicine databases and clinical guidelines. A retrospective study was performed using data collected from the electronic medical records system of Landspítali University Hospital for all patients, 18 years and older that had parenteral naloxon administered in the years 2010–2014. Information about the type of opioid and other respiratory depressive drugs was collected and the data was further investigated in regards to age, gender, and type of service. Results The most potential drugs and drug classes that can cause respiratory depression when used concomitantly with opioids are benzodiazepines and other anxiolytics, hypnotics and sedatives, antipsychotics, antiepileptics, antihistamins and anesthetics. When use was examined (N=138) morphine was the most frequent opioid given (49%). Concomitant use of opioids and other respiratory depressive drugs was seen in 63% of cases, and benzodiazepines were the most frequent drugs given with opioids (33%). Conclusions The concomitant use of benzodiazepines and other sedative drugs with opioids is frequent, despite the known risk of additive respiratory depression as described in the literature. Other patient risk factors such as medical condition, general health and consciousness should be considered in context with drugs used.

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