Computerized Medical Record-Keeping

1986 ◽  
Vol 16 (4) ◽  
pp. 625-646 ◽  
Author(s):  
Frederick R. Rude
Endoscopy ◽  
2006 ◽  
Vol 37 (12) ◽  
Author(s):  
D Debnath ◽  
M Hutcheson ◽  
JK Hussey

2016 ◽  
Vol 07 (04) ◽  
pp. 1154-1167
Author(s):  
Jaycelyn Holland ◽  
Stuart Weinberg ◽  
S. Rosenbloom ◽  
Laura Kaufman

Summary Background Approximately one fifth of school-aged children spend a significant portion of their year at residential summer camp, and a growing number have chronic medical conditions. Camp health records are essential for safe, efficient care and for transitions between camp and home providers, yet little research exists regarding these systems. Objective To survey residential summer camps for children to determine how camps create, store, and use camper health records. To raise awareness in the informatics community of the issues experienced by health providers working in a special pediatric care setting. Methods We designed a web-based electronic survey concerning medical recordkeeping and healthcare practices at summer camps. 953 camps accredited by the American Camp Association received the survey. Responses were consolidated and evaluated for trends and conclusions. Results Of 953 camps contacted, 298 (31%) responded to the survey. Among respondents, 49.3% stated that there was no computer available at the health center, and 14.8% of camps stated that there was not any computer available to health staff at all. 41.1% of camps stated that internet access was not available. The most common complaints concerning recordkeeping practices were time burden, adequate completion, and consistency. Conclusions Summer camps in the United States make efforts to appropriately document healthcare given to campers, but inconsistency and inefficiency may be barriers to staff productivity, staff satisfaction, and quality of care. Survey responses suggest that the current methods used by camps to document healthcare cause limitations in consistency, efficiency, and communications between providers, camp staff, and parents. As of 2012, survey respondents articulated need for a standard software to document summer camp healthcare practices that accounts for camp-specific needs. Improvement may be achieved if documentation software offers the networking capability, simplicity, pediatrics-specific features, and avoidance of technical jargon. Citation: Kaufman L, Holland J, Weinberg S, Rosenbloom ST. Medical record keeping in the summer camp setting.


2003 ◽  
Vol 33 (3) ◽  
pp. 192-192
Author(s):  
Bissallah Ekele

2015 ◽  
Vol 30 (2) ◽  
pp. 216-222 ◽  
Author(s):  
Anisa J. N. Jafar ◽  
Ian Norton ◽  
Fiona Lecky ◽  
Anthony D. Redmond

AbstractBackgroundMedical records are a tenet of good medical practice and provide one method of communicating individual follow-up arrangements, informing research data, and documenting medical intervention.MethodsThe objective of this review was to look at one source (the published literature) of medical records used by foreign medical teams (FMTs) in sudden onset disasters (SODs). The published literature was searched systematically for evidence of what medical records have been used by FMTs in SODs.FindingsThe style and content of medical records kept by FMTs in SODs varied widely according to the published literature. Similarly, there was great variability in practice as to what happens to the record and/or the data from the record following its use during a patient encounter. However, there was a paucity of published work comprehensively detailing the exact content of records used.InterpretationWithout standardization of the content of medical records kept by FMTs in SODs, it is difficult to ensure robust follow-up arrangements are documented. This may hinder communication between different FMTs and local medical teams (LMTs)/other FMTs who may then need to provide follow-up care for an individual. Furthermore, without a standard method of reporting data, there is an inaccurate picture of the work carried out. Therefore, there is not a solid evidence base for improving the quality of future response to SODs. Further research targeting FMTs and LMTs directly is essential to inform any development of an internationally agreed minimum data set (MDS), for both recording and reporting, in order that FMTs can reach the World Health Organization (WHO) standards for FMT practice.JafarAJN, NortonI, LeckyF, RedmondAD. A literature review of medical record keeping by foreign medical teams in sudden onset disasters. Prehosp Disaster Med. 2015;30(2):1-7.


2021 ◽  
Vol 6 (4) ◽  
pp. 723-730
Author(s):  
Priti Kana Barua ◽  
Ashees Kumar Saha ◽  
Jay Priya Borua ◽  
Shampa Barua ◽  
Nasima Akhter ◽  
...  

Medical record is the most important document in the medical field. This cross sectional study was conducted at Chittagong Medical College hospital from January to December, 2017 with the aim to assess the existing medical record keeping practices. Around 214 patients’ record files were selected by systematic sampling method and 30 record keeping personnel were also interviewed. Data were collected by review of records by observational checklist and semi-structured questionnaire were administered to medical record keeping personnel. This study showed that, out of 44 items of patient record file among them 33 items were recorded in 100%. Majority of the medical records (89.7%) were satisfactorily completed. All of the respondents mentioned that they had no training regarding medical record keeping practices. All the respondents stated that some problem faced during keeping the medical record and (90.0%) respondents stated that computerized medical record system could solve the problem they faced. This study showed that, the medical recording status is good in majority areas but keeping practice was not organized at all. There were important defects in keeping the medical records. It seems that there are multiple factors contributing to the problem, such as lack of manpower, insufficient record room and they had no training about medical record keeping practice. It is necessary for the government to develop policies and strategies to improve medical record keeping practice for patient safety, to reduce error, repetition of investigations, protect the medico legal issues and future health care advancement. Asian J. Med. Biol. Res. December 2020, 6(4): 723-730


2006 ◽  
Vol 166 (11) ◽  
pp. 1234
Author(s):  
Steven Safyer ◽  
Eran Bellin

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