scholarly journals The Electronic Medical Record, Lawrence Weed, and the Quality of Clinical Documentation

2020 ◽  
Author(s):  
John F. Reinus
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Clinical Documentation

scholarly journals Structured clinical documentation in the electronic medical record to improve quality and to support practice-based research in epilepsy

Epilepsia ◽  
2016 ◽  
Vol 58 (1) ◽  
pp. 68-76 ◽  
Author(s):  
Jaishree Narayanan ◽  
Sofia Dobrin ◽  
Janet Choi ◽  
Susan Rubin ◽  
Anna Pham ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Clinical Documentation ◽  
Improve Quality ◽  
Practice Based Research

Providing Inclusive Care for Transgender Patients: Capturing Sex and Gender in the Electronic Medical Record

2020 ◽  
Author(s):  
Khushbu Patel ◽  
Martha E Lyon ◽  
Hung S Luu
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Standards Of Care ◽  
Sex And Gender ◽  
Care Providers ◽  
Care Environment ◽  
Gender Nonconforming ◽  
Gender Information ◽  
And Gender

Abstract Background Providing a positive patient experience for transgender individuals includes making the best care decisions and providing an inclusive care environment in which individuals are welcomed and respected. Over the past decades, introduction of electronic medical record (EMR) systems into healthcare has improved quality of care and patient outcomes through improved communications among care providers and patients and reduced medical errors. Promoting the highest standards of care for the transgender populations requires collecting and documenting detailed information about patient identity, including sex and gender information in both the EMR and laboratory information system (LIS). Content As EMR systems are beginning to incorporate sex and gender information to accommodate transgender and gender nonconforming patients, it is important for clinical laboratories to understand the importance and complexity of this endeavor. In this review, we highlight the current progress and gaps in EMR/LIS to capture relevant sex and gender information. Summary Many EMR and LIS systems have the capability to capture sexual orientation and gender identity (SOGI). Fully integrating SOGI into medical records can be challenging, but is very much needed to provide inclusive care for transgender individuals.

scholarly journals Integrating Patient-Generated Health Data in an Electronic Medical Record: Stakeholders’ Perspectives

2020 ◽  
Author(s):  
Katherine Blondon ◽  
Frederic Ehrler
Keyword(s):  
Patient Safety ◽  
Quality Of Care ◽  
Focus Group ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Health Data ◽  
Improve Quality

Patient-generated health data (PGHD), when shared with the provider, provides potential as an approach to improve quality of care. Based on interviews and a focus group with stakeholders involved in PGHD integration in the electronic medical record (EMR), we explore the benefits, barriers and possible risks. We propose solutions to address liability concerns, such as clarifying patient and provider expectations for the analyses of PGHD and emphasize considerations for future steps, which include the need to screen PGHD for patient safety.

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

scholarly journals Transcranial Doppler Ultrasound Screening in Urban Pediatric Sickle Cell Center - Better Charting Improves Compliance over Published Rates

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4749-4749
Author(s):  
Ariel Gliksberg ◽  
Christopher McCauley ◽  
Lewis L. Hsu
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Sickle Cell ◽  
Research Funding ◽  
Chart Review ◽  
Ultrasound Screening ◽  
Patients Âgés ◽  
Lost To Follow Up

Abstract Background: TranscranialDoppler ultrasound (TCD) screening for stroke risk is one of the major advances in pediatric sickle cell disease, since the landmark STOP study. TCD screening is among the measures for quality of pediatric sickle cell care proposed by expert consensus (Wang 2011, NHLBI guidelines 2014). Reeves et al 2016 shows that TCD screening rates are low but still improving (22% in 2006 -44% in 2010). To improve the quality-of-care provided to pediatric sickle cell patients at University of Illinois Hospital, we conducted chart review in 2014 to establish a baseline report of UI Hospitalsadherence to the expert care standards. At that time TCD screening rates were much lower than immunization rates. We then introduced a reminder table in the electronic medical record. 18 months since this change in EMR we re-evaluated our compliance with TCDs. Objectives: To evaluate the improvement atUIHealthpediatric sickle cell clinic compliance with annual TCD. Methods: A manual chart review of these pediatric sickle cell patients was employed to determine adherence to TCD screening standards. All patients ages 2-16yowith SCD-SS and SCD-S/Beta-0-thalassemia that were seen in pediatric sickle cell clinic and adolescent-adult transition clinics two times over 15 months from 2/1/15-5/1/16 were included in study. TCD compliance was determined if patient had TCD between 5/1/2015 through 5/31/16. 5-15 minutes per patient was spent evaluating EMR for TCD compliance Data from the 2014 previous study was also re-evaluated using the same criteria of 2 visits within 15 months of original study date and TCD within 1 year of study. Results: In this work, the charts of 91 pediatric SCD-SS and SCD-S/Beta0 patients were reviewed (ages 2-16 years; M: 34 F 28, 5 ineligible [2 on chronic transfusion, 1 high hemoglobin, 1 yearly MRI, 1 last visit before 2yo]. Lost to follow-up (Seen in clinic since 2014 but not 2 visits from 2/1/15-5/1/16): 24 The rate of TCD screening among these eligible children was 53 out of 62, or 85.5% in 2016. Comparable figures from the 2014 chart review were 17 out of 27, or 63% in 2014. Fishers exact test indicates that this was a significant improvement, p=0.05. Conclusions: We focused our quality-improvement efforts onTranscranialDoppler screening, adding a reminder table in the Electronic Medical Record then re-assessing 18 months later. The rate of TCD screening significantly improved from 63% to 85%. Although less than 100%, these compare favorably to other published TCD rates (Table). The next step is to improve clinic attendance and tracking, to reduce the rate of patients who are "lost to follow-up." To facilitate future chart reviews we have incorporated the key parameters into our "Screening & Management Table" as a component of the electronic medical record. Table Table. Disclosures Hsu: Purdue Pharma: Research Funding; Mast Therapeutics: Research Funding; Eli Lilly: Research Funding; Sancilio: Research Funding; Centers for Medicare and Medicaid Innovation: Research Funding; Pfizer: Consultancy, Research Funding; EMMI Solutions: Consultancy; Gerson Lehman Group: Consultancy; Astra Zeneca: Consultancy, Research Funding; Hilton Publishing: Consultancy, Research Funding.

scholarly journals Nurses’ Views on the Use, Quality, and Satisfaction with Electronic Medical Record in the Outpatient Department at a Tertiary Hospital

2021 ◽  
Vol 15 (1) ◽  
pp. 254-261
Author(s):  
Mohammad J. Jaber ◽  
Ahmad M. Al-Bashaireh ◽  
Ola M. Alqudah ◽  
Omar M. Khraisat ◽  
Khaldoun M. Hamdan ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
English Language ◽  
Daily Practice ◽  
Tertiary Hospital ◽  
Outpatient Department ◽  
Validity And Reliability ◽  
Cross Sectional ◽  
Positive Correlations

Background: Many nurses perceive that the Electronic Medical Record (EMR) reduces the workload, improves the quality of documentation, and improves safety and patient care. However, other nurses reported that the system and environment of healthcare might impede EMR documentation at the bedside. Objective: The study aimed to describe the nurses' views of the use, quality, and satisfaction with EMR in daily practice in outpatient settings. Furthermore, the relationships among the use, quality, and user’s satisfaction of EMR were assessed in the study. Methods: The proposed study employed a cross-sectional, descriptive correlational design. Inclusion criteria were nurses willing to participate in the study, fluent in the English language, and have been working in the Outpatient Department for more than three months until the time of study implementation. A self-reported questionnaire with strong validity and reliability was used to assess nurses’ views of use, quality and satisfaction of EMR. Results: The response rate was 77.2% (170 out of 220), 91.2% of the participants were females. Results about the use of EMR have shown positive views ranging from 51.2% to 84.7%, with the lowest scores reported when to write nurse care worksheets (Kardex). For the quality of EMR, the results have shown positive views ranging from 70% to 87.6% with the lowest scores reported related to the EMR system problems and crashes, and for the user’s satisfaction, the results have shown positive views ranging from 76.5% to 87.1%. There were significant positive correlations between the three elements use, quality, and user’s satisfaction of EMR. Conclusion: Participants reported positive views in the domain of use, quality, and satisfaction with EMR. Furthermore, positive correlations were reported between the use, quality, and satisfaction domains of EMR.

How patients describe their diagnosis compared to clinical documentation

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Kelly Gleason ◽  
Maria R. Dahm
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Clinical Documentation ◽  
Inclusion Criteria ◽  
Technical Language ◽  
Patient Reported ◽  
The One ◽  
The Given

Abstract Objectives To explore how patients describe their diagnoses following Emergency Department (ED) discharge, and how this compares to electronic medical record (EMR) documentation. Methods We conducted a cohort study of patients discharged from three EDs. Patients completed questionnaires regarding their understanding of their diagnosis. Inclusion criteria: adult ED patients aged 18 and older seen within the last seven days. We independently compared patient-reported new diagnoses following discharge to EMR-documented diagnoses regarding diagnostic content (identical, insignificantly different, different, not enough detail) and the level of technical language in diagnostic description (technical, semi-technical, lay). Results The majority of participants (n=95 out of 137) reported receiving a diagnosis and stated the given diagnosis. Of those who reported their diagnosis, 66%, were females (n=62), the average age was 43 (SD 16), and a fourth (n=24) were Black and 66% (n=63) were white. The majority (84%) described either the same or an insignificantly different diagnosis. For 11% the patient-reported diagnosis differed from the one documented. More than half reported their diagnosis using semi-technical (34%) or technical language (26%), and over a third (40%) described their diagnosis in lay language. Conclusions Patient-reported diagnoses following ED discharge had moderate agreement with EMR-documented diagnoses. Findings suggest that patients might reproduce verbatim semi-technical or technical diagnoses they received from clinicians, but not fully understood what the diagnosis means for them.

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