A Literature Review of Medical Record Keeping by Foreign Medical Teams in Sudden Onset Disasters

2015 ◽  
Vol 30 (2) ◽  
pp. 216-222 ◽  
Author(s):  
Anisa J. N. Jafar ◽  
Ian Norton ◽  
Fiona Lecky ◽  
Anthony D. Redmond
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Sudden Onset ◽  
World Health ◽  
Publication Type ◽  
Data Set ◽  
Record Keeping ◽  
Medical Teams

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.

Emergency Surgery Data and Documentation Reporting Forms for Sudden-Onset Humanitarian Crises, Natural Disasters and the Existing Burden of Surgical Disease

2012 ◽  
Vol 27 (6) ◽  
pp. 577-582 ◽  
Author(s):  
Frederick M. Burkle ◽  
Jason W. Nickerson ◽  
Johan von Schreeb ◽  
Anthony D. Redmond ◽  
Kelly A. McQueen ◽  
...  
Keyword(s):  
Natural Disasters ◽  
Emergency Surgery ◽  
Large Scale ◽  
Sudden Onset ◽  
World Health ◽  
Surgical Patient ◽  
Publication Type ◽  
Surgical Disease ◽  
Humanitarian Crises ◽  
Medical Teams

AbstractFollowing large-scale disasters and major complex emergencies, especially in resource-poor settings, emergency surgery is practiced by Foreign Medical Teams (FMTs) sent by governmental and non-governmental organizations (NGOs). These surgical experiences have not yielded an appropriate standardized collection of data and reporting to meet standards required by national authorities, the World Health Organization, and the Inter-Agency Standing Committee's Global Health Cluster. Utilizing the 2011 International Data Collection guidelines for surgery initiated by Médecins Sans Frontières, the authors of this paper developed an individual patient-centric form and an International Standard Reporting Template for Surgical Care to record data for victims of a disaster as well as the co-existing burden of surgical disease within the affected community. The data includes surgical patient outcomes and perioperative mortality, along with referrals for rehabilitation, mental health and psychosocial care. The purpose of the standard data format is fourfold: (1) to ensure that all surgical providers, especially from indigenous first responder teams and others performing emergency surgery, from national and international (Foreign) medical teams, contribute relevant and purposeful reporting; (2) to provide universally acceptable forms that meet the minimal needs of both national authorities and the Health Cluster; (3) to increase transparency and accountability, contributing to improved humanitarian coordination; and (4) to facilitate a comprehensive review of services provided to those affected by the crisis.BurkleFMJr, NickersonJW, von SchreebJ, RedmondAD, McQueenKA, NortonI, RoyN. Emergency surgery data and documentation reporting forms for sudden-onset humanitarian crises, natural disasters and the existing burden of surgical disease. Prehosp Disaster Med.2012;27(6):1-6.

scholarly journals Current Status of the Japanese Disaster Medical Record

2019 ◽  
Vol 34 (s1) ◽  
pp. s114-s114
Author(s):  
Kayako Chishima ◽  
Yoshiki Toyokuni ◽  
Kondo Hisayoshi ◽  
Yuichi Koido ◽  
Tatsuhiko Kubo
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Local Governments ◽  
Current Status ◽  
Actual Condition ◽  
Standard Format ◽  
Torrential Rain ◽  
Record Keeping ◽  
Western Japan ◽  
Medical Teams

Introduction:There was no common medical record used in disasters in Japan. At the 2011 Great East Japan Earthquake, medical teams used their own medical records instead of a unified format and operational rules. As a result, confusion occurred at the clinical practice site. The Joint Committee on Medical Records proposed a standard format of disaster medical records in February 2015. The Ministry of Health, Labor, and Welfare has issued the notification of states’ use of a standardized medical record for disaster in 2017. It was confirmed that standardized disaster medical records were used by each organization in the 2018 Western Japan torrential rain disaster and the Hokkaido Iburi Eastern Earthquake, but the actual condition of those records was not clarified.Methods:We sent a questionnaire to the local governments where the medical team worked in 2018 Western Japan torrential rain disaster and the Hokkaido Iburi Eastern Earthquake. In the questionnaire, we asked about the operation and management of standardized disaster medical records at the time of the disaster and also questioned future management methods.Results:There was no use of other medical records. Standardized medical records were used in all records. All records were managed and operated by the disaster medical headquarters responsible for health care and welfare. Standardized disaster medical records were recorded on paper. Evacuees included patients who moved from shelter to shelter or to temporary housing to get better living conditions. That created difficulties transferring records since it was recorded on paper and stored in medical headquarters. Some returning patients were checked by several medical teams, resulting in the creation of several medical records of the same patient’s condition. Future improvements and management of the recording process and record-keeping are required.

scholarly journals Automatic Placement of Genomic Research Results in Medical Records: Do Researchers Have a Duty? Should Participants Have a Choice?

2015 ◽  
Vol 43 (4) ◽  
pp. 827-842
Author(s):  
Anya E.R. Prince ◽  
John M. Conley ◽  
Arlene M. Davis ◽  
Gabriel Lázaro-Muñoz ◽  
R. Jean Cadigan
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Genomic Research ◽  
Research Results ◽  
Research Participants ◽  
Difficult Question ◽  
Automatic Placement ◽  
Study Participants ◽  
Research Studies

The growing practice of returning individual results to research participants has revealed a variety of interpretations of the multiple and sometimes conflicting duties that researchers may owe to participants. One particularly difficult question is the nature and extent of a researcher’s duty to facilitate a participant’s follow-up clinical care by placing research results in the participant’s medical record. The question is especially difficult in the context of genomic research. Some recent genomic research studies — enrolling patients as participants — boldly address the question with protocols dictating that researchers place research results directly into study participants’ existing medical records, without participant consent. Such privileging of researcher judgment over participant choice may be motivated by a desire to discharge a duty that researchers perceive themselves as owing to participants. However, the underlying ethical, professional, legal, and regulatory duties that would compel or justify this action have not been fully explored.

scholarly journals Surgical outcomes of acute acquired comitant esotropia of adulthood

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Dae Hyun Kim ◽  
Ha Jeong Noh
Keyword(s):  
Success Rate ◽  
Surgical Outcomes ◽  
Medical Records ◽  
Large Angle ◽  
Sudden Onset ◽  
Prism Diopter ◽  
Factors Affecting ◽  
The Mean ◽  
Motor Outcomes

Abstract Background Acute acquired comitant esotropia (AACE) is a type of strabismus characterized by a sudden onset of large angle esotropia with diplopia, which often occurs in children after infancy, teenagers, and young adolescents. However, studies on the surgical outcomes of only adults are rare. The purpose of this article is to analyze the surgical outcomes for adult patients diagnosed with AACE. Methods Medical records of 24 patients who had undergone surgery for AACE were retrospectively analyzed. The main outcome measures were the final motor and sensory success rate after surgery and factors affecting motor and sensory outcomes. Motor success was considered alignment within 8 prism diopter (PD) at both near and distance and sensory success was stereoacuity ≥ 60 sec/arc. Results The preoperative mean esodeviation angles were 33.1 ± 10.4 PD at distance and 33.3 ± 11.2 PD at near. The mean period of postoperative follow up was 7.5 ± 4.5 months (range 1–8 months). The postoperative mean esodeviation angles at final follow-up time were 3.4 ± 6.1 PD at distance and 3.8 ± 6.7 PD at near. The surgical motor success rate at final follow-up was 79.2% (19/24). The sensory success rate at final follow-up was 50.0% (12/24). The factor affecting the motor outcome was the type of surgery (p < 0.05). The factor affecting sensory outcome was postoperative follow-up time (p < 0.05). Conclusions Surgery type appears to affect surgical motor outcomes in adults with AACE. Although the sensory outcome was favorable, it seems that regaining bifoveal fixation takes time.

scholarly journals Study Literature Review On Returning Medical Record Documents Using HOT-FIT Method

2021 ◽  
Vol 1 (1) ◽  
pp. 61-65
Author(s):  
Deni Maisa Putra ◽  
Oktamianiza Oktamianiza ◽  
Mega Yuniar ◽  
Washi Fadhila
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Descriptive Analysis ◽  
Net Benefit ◽  
Literature Study ◽  
Return Policy ◽  
Record Section ◽  
Doctors And Nurses

The return of medical record files is a system that is quite important in medical records, because the return of medical records starts from the file in the inpatient room until it returns to the medical record section in accordance with the return policy, which is 2x24 hours. The method used is a literature study with descriptive analysis which is done by describing the facts that exist then being analyzed, described, looking for similarities, views, and summaries of several studies. The results of the literature study show that humans are not responsible for returning medical record files, the organization lacks supervision from the management of returning files, technology (technology) with technology can assist in returning medical record files. So it is necessary to pay attention to the 3 components, so that it can produce a benefit (Net Benefit) from returning the medical record document. Based on the results of the study, it can be concluded that the factors that influence the return of medical record documents are in terms of the HOT-FIT method, (human) where the officers lack a sense of responsibility for medical record documents, and doctors and nurses do not pay attention to the form of filling out record documents medical records, so that it becomes an obstacle in returning medical record documents. It's good to have good supervision from the management.

scholarly journals Medical record keeping practices in a tertiary level hospital

2021 ◽  
Vol 6 (4) ◽  
pp. 723-730
Author(s):  
Priti Kana Barua ◽  
Ashees Kumar Saha ◽  
Jay Priya Borua ◽  
Shampa Barua ◽  
Nasima Akhter ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Cross Sectional Study ◽  
Systematic Sampling ◽  
Future Health ◽  
College Hospital ◽  
Record System ◽  
Cross Sectional ◽  
Record Keeping ◽  
The Government

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

scholarly journals Estimates of mortality rates in people with diabetes and cardiovascular disease using administrative pharmaceutical data

2019 ◽  
Vol 4 (3) ◽  
Author(s):  
Shaun Purkiss ◽  
Tessa Keegel ◽  
Hassan Vally ◽  
Dennis Wollersheim
Keyword(s):  
Cardiovascular Disease ◽  
Mortality Risk ◽  
Age Groups ◽  
Mortality Rates ◽  
World Health ◽  
Data Set ◽  
Medication Discontinuation ◽  
Disease Mortality ◽  
Health Organization

BackgroundQuantifying the mortality risk for people with diabetes is challenging because of associated comorbidities. The recording of cause specific mortality from accompanying cardiovascular disease in death certificate notifications has been considered to underestimate the overall mortality risk in persons with diabetes. Main AimDevelop a technique to quantify mortality risk from pharmaceutical administrative data and apply it to persons diagnosed with diabetes, and associated cardiovascular disease and dyslipidaemia before death. MethodsPersons with diabetes, cardiovascular disease and dyslipidaemia were identified in a publicly available Australian Pharmaceutical data set using World Health Organization anatomic therapeutic codes assigned to medications received. Diabetes associated multi-morbidity cohorts were constructed and a proxy mortality (PM) event determined from medication and service discontinuation. Estimates of mortality rates were calculated from 2004 for 10 years and compared persons with diabetes alone and associated cardiovascular disease and dyslipidemia. ResultsThis study identified 346,201 individuals within the 2004 calendar year as having received treatments for diabetes (n=51,422), dyslipidaemia (n=169,323) and cardiovascular disease including hypertension (n=280,105). Follow up was 3.3 x 106 person-years. Overall crude PM was 26.1 per 1000 person-years. PM rates were highest in persons with cardiovascular disease and diabetes in combination (47.5 per 100 person years). Statin treatments significantly improved the mortality rates in all persons with diabetes and cardiovascular disease alone and in combination over age groups >44 years (p<.001). Age specific diabetes PM rates using pharmaceutical data correlated well with Australian data from the National Diabetes Service Scheme (r=0.82) ConclusionProxy mortality events calculated from medication discontinuation in persons with chronic conditions can provide an alternative method to estimate disease mortality rates. The technique also allows the assessment of mortality risk in persons with chronic disease multi-morbidity.

scholarly journals Polypharmacy in Middle-European Rheumatoid Arthritis-Patients: A Retrospective Longitudinal Cohort Analysis With Systematic Literature Review

2020 ◽  
Vol 7 ◽  
Author(s):  
Jacqueline Désirée Jack ◽  
Rick McCutchan ◽  
Sarah Maier ◽  
Michael Schirmer
Keyword(s):  
Rheumatoid Arthritis ◽  
Literature Review ◽  
Systematic Literature Review ◽  
Anatomical Therapeutic Chemical ◽  
Cohort Analysis ◽  
World Health ◽  
Management Guidelines ◽  
The Mean ◽  
Health Organization

Objective: To assess polypharmacy and related medication aspects in Middle-European rheumatoid arthritis (RA) patients, and to discuss the results in view of a systematic literature review.Methods: In this retrospective cohort study, charts were reviewed from RA-patients consecutively recruited between September 27, 2017 and April 29, 2019. Drugs were assigned to the Anatomical Therapeutic Chemical (ATC) groups as proposed by the World Health Organization (WHO). Results were compared to those of a systematic literature review.Results: One hundred seventy-five consecutive RA-patients were included. The mean number of drugs was 6.6 ± 3.5, with 2.4 ± 1.2 drugs taken specifically for RA—compared to 2.6 in the literature. 33.7% of patients experienced polypharmacy defined by ≥5 drugs, compared to 61.6% in the literature–with women affected more frequently than men. After 7 years of follow-up, the number of drugs increased in all ATC-groups by an average of 12.7 %, correlating with age (Corrcoeff = 0.46) and comorbidities (Corrcoeff = 0.599). In the literature, polypharmacy is not always defined precisely, and has not been considered in management guidelines so far.Conclusion: Polypharmacy is a frequent issue in RA-management. With an increasing number of comorbidities during the course of the disease, polypharmacy becomes even more relevant.

Foreign Field Hospitals in the Recent Sudden-Onset Disasters in Iran, Haiti, Indonesia, and Pakistan

2008 ◽  
Vol 23 (2) ◽  
pp. 144-151 ◽  
Author(s):  
Johan von Schreeb ◽  
Louis Riddez ◽  
Hans Samnegård ◽  
Hans Rosling
Keyword(s):  
Trauma Care ◽  
Sudden Onset ◽  
World Health ◽  
Essential Requirement ◽  
Medical Trauma ◽  
Key Informant ◽  
Pan American ◽  
Health Organization ◽  
Secondary Information

AbstractIntroduction:Foreign field hospitals (FFHs) may provide care for the injured and substitute for destroyed hospitals in the aftermath of sudden-onset disasters.Problem:In the aftermath of sudden-onset disasters, FFHs have been focused on providing emergency trauma care for the initial 48 hours following the sudden-onset disasters, while they tend to be operational much later. In addition, many have remained operational even later. The aim of this study was to assess the timing, activities, and capacities of the FFHs deployed after four recent sudden-onset disasters, and also to assess their adherence to the essential criteria for FFH deployment of the World Health Organization (WHO).Methods:Secondary information on the sudden-onset disasters in Bam, Iran in 2003, Haiti in 2004, Aceh, Indonesia in 2004, and Kashmir, Pakistan in 2005, including the number of FFHs deployed, their date of arrival, country of origin, length of stay, activities, and costs was retrieved by searching the Internet.Additional information was collected on-site in Iran, Indonesia, and Pakistan through direct observation and key informant interviews.Results:Basic information was found for 43 FFHs in the four disasters. The first FFH was operational on Day 3 in Bam and Kashmir, and on Day 8 in Aceh. The first FFHs were all from the militaries of neighboring countries. The daily cost of a bed was estimated to be US$2,000. The bed occupancy rate generally was <50%. None of the 43 FFHs met the first WHO/Pan-American Health Organization (PAHO) essential requirement if the aim is to provide emergency trauma care, while 15% followed the essential requirement if follow-up trauma and medical care is the aim of deployment.Discussion:A striking finding was the lack of detailed information on FFH activities. None of the 43 FFHs arrived early enough to provide emergency medical trauma care. The deployment of FFHs following sudden-onset disasters should be better adapted to the main needs and the context and more oriented toward substituting for pre-existing hospitals, rather than on providing immediate trauma care.

scholarly journals Pengembangan Sistem Informasi Rekam Medis untuk Dinas Kabupaten Grobogan

2014 ◽  
Vol 2 (3) ◽  
pp. 203-208
Author(s):  
Purnaresa Yuliartanto ◽  
Adian Fatchur Rochim ◽  
Ike Pertiwi Windasari
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Business Processes ◽  
Health Department ◽  
Health Centers ◽  
Process Data ◽  
Record Keeping ◽  
Storage And Retrieval ◽  
Number Of Patients

Abstract - Health services include the recording of the patient's medical record . Medical records were used to aid the treatment process. The number of medical records continues to grow proportional to the number of patients. Tens of thousands of sheets of paper used to record medical record requires effort , time and place great . The amount of effort will continue to grow each day. Search one sheet of medical records among a set of storage shelves requires considerable time and risk data is not found. The risk of error in the search and storing will increase every day. The development of technology allows the implementation of technology in the process of record-keeping. Changes in the form of digital medical records will reduce the need of a previous process. Labor, time and place required by the help of information systems will be reduced significantly . Storage process data stored in the cloud will provide more value for the system as a patient's medical records from a health center can be accessed from other health centers. The development of this system will reduce the risk of inappropriate storage and retrieval of medical records. Grobogan Health Department that oversees health center in Grobogan are office that are ready to migrate business processes into the digital age. Development of medical record information system for the health center expected to improve the quality of service of health centers , especially in health care.

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