Computerization of the Patient History -Patient Answers Compared with Medical Records

1986 ◽  
Vol 25 (04) ◽  
pp. 222-228 ◽  
Author(s):  
M. J. Quaak ◽  
R. F. Westerman ◽  
J. A. Schouten ◽  
A. Hasman ◽  
J. H. Bemmel
Keyword(s):  
Internal Medicine ◽  
Medical Records ◽  
Patient Record ◽  
Frequency Of Occurrence ◽  
History Taking ◽  
Patient History ◽  
Patient Complaints ◽  
Computerized Patient Record ◽  
Extensive Information ◽  
Experienced Physician

SummaryComputerized medical history taking, in which patients answer questions by using a terminal, is compared with the written medical record for a group of 99 patients in internal medicine. Patient complaints were analysed with respect to their frequency of occurrence for all important tracts, such as the respiratory, the gastro-intestinal and the uro-genital tracts. About 36% of over 3,200 patient answers were identical in the patient record and the written record, but a considerable percentage of complaints (56%), that were present in the patient record, were missing in the written record; the reverse was true for 4.5%. A computerized patient record appears to contain more extensive information about patient complaints, still to be interpreted by the experienced physician.

scholarly journals Comparative study of the prevalence of sepsis in patients admitted to dermatology and internal medicine wards

2013 ◽  
Vol 88 (5) ◽  
pp. 739-747
Author(s):  
Luiz Mauricio Costa Almeida ◽  
Michelle dos Santos Diniz ◽  
Lorena dos Santos Diniz ◽  
Jackson Machado-Pinto ◽  
Francisco Chagas Lima Silva
Keyword(s):  
Internal Medicine ◽  
Comparative Study ◽  
Medical Records ◽  
Skin Barrier ◽  
Epidemiological Studies ◽  
Internal Medicine Ward ◽  
Cross Sectional ◽  
Systemic Corticosteroids ◽  
Internal Medicine Wards ◽  
Belo Horizonte

BACKGROUND: Sepsis is a common cause of morbidity and mortality among hospitalized patients. The prevalence of this condition has increased significantly in different parts of the world. Patients admitted to dermatology wards often have severe loss of skin barrier and use systemic corticosteroids, which favor the development of sepsis. OBJECTIVES: To evaluate the prevalence of sepsis among patients admitted to a dermatology ward compared to that among patients admitted to an internal medicine ward. METHODS: It is a cross-sectional, observational, comparative study that was conducted at Hospital Santa Casa de Belo Horizonte. Data were collected from all patients admitted to four hospital beds at the dermatology and internal medicine wards between July 2008 and July 2009. Medical records were analyzed for the occurrence of sepsis, dermatologic diagnoses, comorbidities, types of pathogens and most commonly used antibiotics. RESULTS: We analyzed 185 medical records. The prevalence of sepsis was 7.6% among patients admitted to the dermatology ward and 2.2% (p = 0.10) among those admitted to the internal medicine ward. Patients with comorbidities, diabetes mellitus and cancer did not show a higher incidence of sepsis. The main agent found was Staphylococcus aureus, and the most commonly used antibiotics were ciprofloxacin and oxacillin. There was a significant association between sepsis and the use of systemic corticosteroids (p <0.001). CONCLUSION: It becomes clear that epidemiological studies on sepsis should be performed more extensively and accurately in Brazil so that efforts to prevent and treat this serious disease can be made more effectively.

scholarly journals The Prevalence of Alprazolam Uses in Geriatric Patients at Dr. Mohammad Hoesin Hospital Palembang

2016 ◽  
Vol 5 (2) ◽  
pp. 193
Author(s):  
Yohanes Febrianto ◽  
Sutomo Tanzil ◽  
Theodorus Parulian
Keyword(s):  
Internal Medicine ◽  
Heart Disease ◽  
Medical Records ◽  
Geriatric Patients ◽  
Age Group ◽  
Internal Medicine Ward ◽  
Drug Utilization Study ◽  
Short Acting ◽  
Infectious Origin ◽  
Male Patients

<p>One of the most frequently prescribed drugs in geriatric patients is a benzodiazepine, especially a short-acting such as alprazolam. Unfortunately, alprazolam is oftenly used inappropriately because this drug has a short acting effect. Geriatric patients are more sensitive to this drug that can lead to the dependence. However, there is still lack of data on the use of this drug in geriatric patients. The aim of this study was to determine the prevalence of the use of alprazolam. A drug utilization study has been done for 2 months through analysis of patient’s medical records in the internal medicine ward at RSMH Palembang from June 1<sup>st</sup>, 2012 to May 31<sup>st</sup>, 2013. There were 25 out of 1634 patients receiving alprazolam, but only 23 patients whose data were obtained from the available medical records. Prevalence of alprazolam use was 1.408%. Based on gender, the prevalence was 1.798% in female and 1.09% in male patients. Proportion by age group was 91.3%, 8.7% and 0% in age group 60-74 years, 75-90 years and over 90 years, respectively. Based on the job, the population study comprised of the housewive (52.1%), unemployment (39.1%), and entrepreneur and farmer (4.3% together). The indication of usage was atheroscerotic heart disease, diarrhoea and gastroenteritis of presumed infectious origin, unspecified gastritis, and thyrotoxic heart disease. In other words, it could be said that the usage of alprazolam was inappropriate.</p>

scholarly journals Inappropriate requests for tumor markers in patients aged 50 years and older: lessons not learned

2021 ◽  
Vol 15 ◽  
Author(s):  
Valter Paz Nascimento-Júnior ◽  
Einstein Francisco Camargos
Keyword(s):  
Internal Medicine ◽  
Health Care ◽  
Health Insurance ◽  
Medical Records ◽  
Private Health Insurance ◽  
Medical Specialty ◽  
Health Care Managers ◽  
Inappropriate Use ◽  
Care Managers ◽  
Previous Diagnosis

OBJECTIVE: To investigate, within a private health insurance, the ordering frequency and the costs related to inappropriate TM test orders. METHODS: This study analyzed data regarding TM requests within a private health insurance between 2010 and 2017. Patients included in this analysis were ≥ 50 years old, had available medical records, and had at least 1 TM tested within the study period. Tests were considered inappropriate when TMs were used in screening for neoplasms, ie, when there was no previous diagnosis. We evaluated data regarding age, sex, the ordering physician’s medical specialty, and test costs. RESULTS: Between 2010 and 2017, 1,112 TM tests were performed and increased from 52 to 262 per year. Our sample consisted mostly of women (69.50%) with a mean age of 59.40 (SD, 8.20) years. Most orders were inappropriate (87.80%) and represented 79.40% of all expenses with TM tests. Cardiology professionals were the medical specialty that requested the most TM tests (23.90%), followed by internal medicine specialists (22.70%) and gynecologists (19.20%). CONCLUSIONS: We observed a high percentage of inappropriate test orders in the study period, resulting in elevated costs. Studies of this nature deserve the attention of health care managers, and interventions should be performed in order to reduce the inappropriate use of TM tests in clinical practice.

scholarly journals Gambaran Faktor Risiko Kejadian Penyakit Jantung Koroner di Poliklinik Jantung RSI Siti Rahmah Padang Tahun 2017-2018

2020 ◽  
Vol 3 (1) ◽  
pp. 20-28
Author(s):  
Yushera Atika Sari ◽  
Wisda Widiastuti ◽  
Betty Fitriyasti
Keyword(s):  
Internal Medicine ◽  
Medical Records ◽  
Univariate Analysis ◽  
Secondary Data ◽  
Sampling Technique ◽  
Cross Sectional ◽  
Long Period ◽  
Survey Results ◽  
Artery Disease ◽  
Descriptive Method

Introduction: CAD occurs indirectly, usually a person will experience a process of narrowing of the coronary arteries in quite a long period of time. Primary survey results that researchers have done at Siti Rahmah Padang Hospital, recorded from 2017-2018 the number of CAD events as many as 115 cases. Aims : To obtain information about an overview of risk factors for the occurrence of coronary artery disease in the heart policlinic of Siti Rahmah Hospital Padang in 2017-2018. Method: This research covers the field of internal medicine and cardiology, this study was conducted at the Islamic hospital Siti Rahmah Padang in May to November 2019. This research used a descriptive method with a cross sectional approach using secondary data from medical records. The affordable population of this study is CAD patients who seek treatment at Siti Rahmah Hospital in Padang in 2017-2018 with 51 samples using Total Sampling technique. Univariate analysis is presented in the form of a frequency distribution table. Results: Based on the results of the study the most age was at the age of 50-59 years, 21 people (41.2%), the most sex was female, 26 people (51%), hypertension, 27 people (52,9%), experienced DM 26 people (51%) were obese, 16 people (31,4%) and hyperlipidemia, 13 people (25,5%). Conclusion : Most age 50-59 years, most sexes of women, most have hypertension, less than half are obese, most have DM and less than half have hyperlipidemia. 

scholarly journals PPX-TEC API APP: A unique approach to sending and receiving health and insurance data

2019 ◽  
Vol 4 (2) ◽  
Keyword(s):  
Medical Record ◽  
Healthcare Systems ◽  
Veterans Affairs ◽  
Patient Record ◽  
Record System ◽  
Medical Record System ◽  
Unique Approach ◽  
Computerized Patient Record ◽  
Insurance Data ◽  
The U.S

In 1971, the U.S. Dept. of Veterans Affairs (VA) became one of the first large healthcare systems to fully implement a computerized patient record system. Shortly thereafter, in 1972, Regenstrief developed the Regenstrief Medical Record System (RMRS), a historically important EMR. The purpose of this early EMR was described in a quote that is still applicable today:

ESTIMATION OF POSSIBILITY OF APPLICATION OF TIGERASE® (DORNASE ALFA) DRUG ON THE RESULTS OF A MULTICENTER SCIENTIFIC PROGRAM OF POST-MARKETING USE OF THE DRUG

2021 ◽  
Vol 100 (3) ◽  
pp. 218-226
Author(s):  
E.I. Kondratyeva ◽  
◽  
V.V. Shadrina ◽  
E.G. Furman ◽  
A.Yu. Voronkova ◽  
...  
Keyword(s):  
Medical Records ◽  
Adverse Reactions ◽  
Clinical Manifestations ◽  
Scientific Program ◽  
Bronchial Secretion ◽  
Patient Complaints ◽  
Clinical Observations ◽  
Number Of Patients ◽  
Gender And Age ◽  
Post Marketing

The aim of the program was to study the tolerability of Tigerase® in patients with cystic fibrosis (CF) of all ages in rutine clinical practice. Study design: retrospective open uncontrolled comparative multicenter solid. Materials and methods of research: retrospective data of clinical observations were collected from medical records of patients with CF on the use of Tigerase®. Results: therapy with Tigerase® was well tolerated by 668 (93,4%) of 715 patients included in the study. In 47 (6,6%) patients, 127 adverse reactions (ADRs) associated with the use of Tigerase® were recorded. ADRs from the respiratory system were the most common. Of these, 24 (3,4%) were coughing and 10 (1,4%) had increased viscosity of bronchial secretion. Among all patients included in the study, the proportion of patients in whom ADRs were registered based on clinical manifestations (3,9%) did not differ statistically significantly from the proportion of patients in whom ADRs were recorded based on complaints only (2,8%) (p=0,30). The distribution of ADRs by the source of registration and place of residence of patients did not depend on their gender and age. Registration of ADRs in different regions of the country differed statistically significantly both in frequency and in the source of detection (p<0,001). ADRs were not recorded in several regions, and the largest number of ADRs were registered in patients living in Moscow, and most of them were based only on patient complaints. 22 patients (47% of the number of patients with ADR) had medical commissions for ADR, and only in 8 (17% of the number of patients with ADR) of them had expertise of specialists with experience in the treatment of patients with CF. In 29 patients (62% of the number of patients with ADR), the development of ADR did not require cessation of the Tigerase® therapy. Conclusion: in the majority of CF patients (93,4%) tolerated the Tigerase® therapy well.

Medical records and history taking

2018 ◽  
Vol 7 (10) ◽  
pp. 538-540
Author(s):  
Gemma Fromage
Keyword(s):  
Medical Records ◽  
History Taking
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