A Computer-oriented Approach to the Comprehensive Organization of Information in Hand-compiled Medical Records

1979 ◽  
Vol 18 (03) ◽  
pp. 138-145 ◽  
Author(s):  
S. Certttti ◽  
E. Longbxni ◽  
F. Pinciholi
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Information Science ◽  
General Medicine ◽  
Practical Experience ◽  
Free Text ◽  
Medical Terminology ◽  
Multidisciplinary Research ◽  
Medicine Department ◽  
New Approach

The problem of the comprehensive organization of the medical record is discussed in this paper. The basis of the organizational scheme is the integration of both fixed-text and free-text components with constraints imposed upon the original formatting of the free text. To support the diagnostic procedure a component of the record is a »diagnosis sheet«, which embodies a differential diagnosis approach and is discussed in detail.Results of more than two years of practical experience in the general medicine department of a regional hospital in Italy are presented. A trend towards a standardization of the medical terminology used was noted. Physicians' acceptance of a more rational conception of the medical record was high and a considerable flexibility in the language employed was observed. Finally, it is important to note that this new approach to the organization of the medical record was conceived in such a way as to make it processable by a computer located within the department itself. The initial experiences with the computerization of the record are presented and discussed with a view to future implementations and implications for cooperative, multidisciplinary research in medicine and information science.

scholarly journals The Application of Projection Word Embeddings on Medical Records Scoring System

Healthcare ◽  
2021 ◽  
Vol 9 (10) ◽  
pp. 1298
Author(s):  
Chin Lin ◽  
Yung-Tsai Lee ◽  
Feng-Jen Wu ◽  
Shing-An Lin ◽  
Chia-Jung Hsu ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Mixed Model ◽  
Linear Mixed Model ◽  
Model Performance ◽  
Absolute Error ◽  
Mixed Linear Model ◽  
Word Embedding ◽  
Word Embeddings ◽  
Medical Terminology

Medical records scoring is important in a health care system. Artificial intelligence (AI) with projection word embeddings has been validated in its performance disease coding tasks, which maintain the vocabulary diversity of open internet databases and the medical terminology understanding of electronic health records (EHRs). We considered that an AI-enhanced system might be also applied to automatically score medical records. This study aimed to develop a series of deep learning models (DLMs) and validated their performance in medical records scoring task. We also analyzed the practical value of the best model. We used the admission medical records from the Tri-Services General Hospital during January 2016 to May 2020, which were scored by our visiting staffs with different levels from different departments. The medical records were scored ranged 0 to 10. All samples were divided into a training set (n = 74,959) and testing set (n = 152,730) based on time, which were used to train and validate the DLMs, respectively. The mean absolute error (MAE) was used to evaluate each DLM performance. In original AI medical record scoring, the predicted score by BERT architecture is closer to the actual reviewer score than the projection word embedding and LSTM architecture. The original MAE is 0.84 ± 0.27 using the BERT model, and the MAE is 1.00 ± 0.32 using the LSTM model. Linear mixed model can be used to improve the model performance, and the adjusted predicted score was closer compared to the original score. However, the project word embedding with the LSTM model (0.66 ± 0.39) provided better performance compared to BERT (0.70 ± 0.33) after linear mixed model enhancement (p < 0.001). In addition to comparing different architectures to score the medical records, this study further uses a mixed linear model to successfully adjust the AI medical record score to make it closer to the actual physician’s score.

scholarly journals Assessing the quality of electronic medical records as a platform for resident education

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Hsuan Hung ◽  
Ling-Ling Kueh ◽  
Chin-Chung Tseng ◽  
Han-Wei Huang ◽  
Shu-Yen Wang ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Assessment Tool ◽  
Medical Training ◽  
General Medicine ◽  
Resident Training ◽  
Obstetrics And Gynaecology ◽  
Overall Performance ◽  
User Friendly

Abstract Background Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants’ medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications. Methods The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA). Results Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92). Conclusions This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.

A Medical Text Analysis System for German - Syntax Analysis

1991 ◽  
Vol 30 (04) ◽  
pp. 275-283 ◽  
Author(s):  
P. M. Pietrzyk
Keyword(s):  
Text Analysis ◽  
Free Text ◽  
New Approach ◽  
Syntax Analysis ◽  
Medical Text ◽  
Medical Language ◽  
Computerized Processing ◽  
Language Data ◽  
Analysis System ◽  
German Syntax

Abstract:Much information about patients is stored in free text. Hence, the computerized processing of medical language data has been a well-known goal of medical informatics resulting in different paradigms. In Gottingen, a Medical Text Analysis System for German (abbr. MediTAS) has been under development for some time, trying to combine and to extend these paradigms. This article concentrates on the automated syntax analysis of German medical utterances. The investigated text material consists of 8,790 distinct utterances extracted from the summary sections of about 18,400 cytopathological findings reports. The parsing is based upon a new approach called Left-Associative Grammar (LAG) developed by Hausser. By extending considerably the LAG approach, most of the grammatical constructions occurring in the text material could be covered.

A Retrieval System for a Library of Pathology Reports, Slides and Kodachromes

1972 ◽  
Vol 11 (03) ◽  
pp. 152-162 ◽  
Author(s):  
P. GAYNON ◽  
R. L. WONG
Keyword(s):  
Medical Records ◽  
Operative Procedure ◽  
Clinical Findings ◽  
Free Text ◽  
X Ray ◽  
Inverted File ◽  
Natural Language Parsing ◽  
On Line ◽  
Pathology Reports ◽  
Frequency Counts

With the objective of providing easier access to pathology specimens, slides and kodachromes with linkage to x-ray and the remainder of the patient’s medical records, an automated natural language parsing routine, based on dictionary look-up, was written for Surgical Pathology document-pairs, each consisting of a Request for Examination (authored by clinicians) and its corresponding report (authored by pathologists). These documents were input to the system in free-text English without manual editing or coding.Two types of indices were prepared. The first was an »inverted« file, available for on-line retrieval, for display of the content of the document-pairs, frequency counts of cases or listing of cases in table format. Retrievable items are patient’s and specimen’s identification data, date of operation, name of clinician and pathologist, etc. The English content of the operative procedure, clinical findings and pathologic diagnoses can be retrieved through logical combination of key words. The second type of index was a catalog. Three catalog files — »operation«, »clinical«, and »pathology« — were prepared by alphabetization of lines formed by the rotation of phrases, headed by keywords. These keywords were automatically selected and standardized by the parsing routine and the phrases were extracted from each sentence of each input document. Over 2,500 document-pairs have been entered and are currently being utilized for purpose of medical education.

Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing (Studi Kasus: Dinas Kesehatan Propinsi Jawa Barat)

2017 ◽  
Vol 8 (3) ◽  
Author(s):  
Ova Nurisma Putra
Keyword(s):  
Cloud Computing ◽  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Monitoring And Evaluation ◽  
Open Group ◽  
Development Method ◽  
Information System Architecture ◽  
Architecture Framework ◽  
Architecture Development

Abstract. West Java Provincial Health Office still faces difficulties in managing information, especially in medical records. Recording and reporting of malnutrition are still done in some stages starting from collecting data from village midwives, puskesmas, Regency/City Health Office then Provincial Health Office and forwarded to the the central office. It is necessary to manage information through service system by utilizing Cloud Computing based on information technology. This research uses The Open Group Architecture Framework (TOGAF) approach in Architecture Development Method (ADM), from Architecture Capability Iteration to  Architecture Development Iteration. Monitoring and Evaluation (M & E) are two integrated activities in the context of controlling a program. The results of this research are planning a medical record information system architecture and monitoring malnutrition based on Cloud Computing with the name of M2Rec (Medical Record and Monitoring) in the form of integrated recommendation and development between current information system and proposed information system architecture.Keywords: togaf adm, medical record and monitoring, cloud computing Abstrak. Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing. Dinas Kesehatan Propinsi Jawa Barat masih mengalami kesulitan dalam pengelolaan informasi yang baik, terutama pada proses rekam medis, pencatatan dan pelaporan gizi buruk masih dilakukan secara bertingkat mulai pengumpulan data dari bidan desa, puskesmas, Dinas Kesehatan Kabupaten/Kota kemudian Dinas Kesehatan Propinsi dan diteruskan ke pusat. Sehingga perlu diupayakan pengelolaan informasi melalui sistem pelayanan dengan memanfaatkan teknologi informasi berbasis Cloud Computing. Penelitian ini menggunakan pendekatan framework The Open Group Architecture Framework (TOGAF) Architecture Development Method (ADM), yaitu iterasi ke satu pada Architecture Capability Iteration daniterasi ke dua pada Architecture Development Iteration. Monitoring dan Evaluasi (M&E) merupakan dua kegiatan terpadu dalam rangka pengendalian suatu program. Hasil dari penelitian ini adalah perencanaan arsitektur sistem informasi rekam medis dan monitoring gizi buruk berbasis Cloud Computing dengan nama M2Rec (Medical Record and Monitoring) yang berupa rekomendasi integrasi dan pengembangan antara sistem informasi berjalan saat ini dengan arsitektur sistem informasi yang diusulkan.Kata kunci: togaf adm, medical record and monitoring, cloud computing.

Analisis Unsur Manajemen dalam Pengolahan Rekam Medis di Rumah Sakit TNI AU Lanud Roesmin Nurjadin

2018 ◽  
Vol 1 (1) ◽  
pp. 20-25
Author(s):  
Henny Maria Ulfa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Processing Method ◽  
Qualitative Approach ◽  
Check List ◽  
Training Material ◽  
Patient Medical Record ◽  
Qualitative Descriptive ◽  
Material Element ◽  
Descriptive Method

Hospitals must conduct a medical record activities according to Permenkes NO.269 / MENKES / PER / III / 2008 about Medical Record, to achieve the purpose of medical record processing required 5 management elements are: man, money, material, machine, and method. The medical record processing that has been implemented at the Hospital TNI AU LANUD Roesmin Nurjadin that is coding, coding only done for BPJS patients whose conducted by the officer with education background of D3 nursing, it be impacted to the storage part is wrong save and cannot found patient medical record file because are not returned. The purpose of this research is to know the element of management in the processing of medical records at the Hospital TNI AU LANUD Roesmin Nurjadin. This research is done by Qualitative descriptive method, Qualitative approach, instrument of data collection of interview guidance, observation guidance, check list register, and stationery, number of informant 6 people with inductive way data analysis. The result of this research found that Mans elements only amounts to 2 people so that officers work concurrently and have never attended training, material element and machines elements of medical record processing not yet use SIMRS and tracer, while processing method elements follow existing habits and follow the policy of hospital that is POP organization. Keywords: Management elements, medical record processing

The use of a Domain Ontology for the Management of Essential Hypertension (Preprint)

2020 ◽  
Author(s):  
Emma Chavez ◽  
Vanessa Perez ◽  
Angélica Urrutia
Keyword(s):  
Decision Making ◽  
Essential Hypertension ◽  
Medical History ◽  
Medical Records ◽  
Medical Training ◽  
Relevant Information ◽  
Domain Ontology ◽  
Free Text ◽  
Snomed Ct ◽  
History Of

BACKGROUND : Currently, hypertension is one of the diseases with greater risk of mortality in the world. Particularly in Chile, 90% of the population with this disease has idiopathic or essential hypertension. Essential hypertension is characterized by high blood pressure rates and it´s cause is unknown, which means that every patient might requires a different treatment, depending on their history and symptoms. Different data, such as history, symptoms, exams, etc., are generated for each patient suffering from the disease. This data is presented in the patient’s medical record, in no order, making it difficult to search for relevant information. Therefore, there is a need for a common, unified vocabulary of the terms that adequately represent the diseased, making searching within the domain more effective. OBJECTIVE The objective of this study is to develop a domain ontology for essential hypertension , therefore arranging the more significant data within the domain as tool for medical training or to support physicians’ decision making will be provided. METHODS The terms used for the ontology were extracted from the medical history of de-identified medical records, of patients with essential hypertension. The Snomed-CT’ collection of medical terms, and clinical guidelines to control the disease were also used. Methontology was used for the design, classes definition and their hierarchy, as well as relationships between concepts and instances. Three criteria were used to validate the ontology, which also helped to measure its quality. Tests were run with a dataset to verify that the tool was created according to the requirements. RESULTS An ontology of 310 instances classified into 37 classes was developed. From these, 4 super classes and 30 relationships were obtained. In the dataset tests, 100% correct and coherent answers were obtained for quality tests (3). CONCLUSIONS The development of this ontology provides a tool for physicians, specialists, and students, among others, that can be incorporated into clinical systems to support decision making regarding essential hypertension. Nevertheless, more instances should be incorporated into the ontology by carrying out further searched in the medical history or free text sections of the medical records of patients with this disease.

scholarly journals Adult Learning Principles and Peer Delivery Improve Satisfaction of Electronic Medical Record Onboarding Education

ACI Open ◽  
2020 ◽  
Vol 04 (02) ◽  
pp. e114-e118
Author(s):  
Joanna Lawrence ◽  
Sharman Tan Tanny ◽  
Victoria Heaton ◽  
Lauren Andrew
Keyword(s):  
Adult Learning ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Junior Doctors ◽  
Free Text ◽  
Organizational Safety ◽  
Adult Learning Principles ◽  
Learning Practices ◽  
Learning Principles ◽  
The Impact

Abstract Objectives Given the importance of onboarding education in ensuring the safety and efficiency of medical users in the electronic medical record (EMR), we re-designed our EMR curriculum to incorporate adult learning principles, informed and delivered by peers. We aimed to evaluate the impact of these changes based on their satisfaction with the training. Methods A single site pre- and post-observational study measured satisfaction scores (four questions) from junior doctors attending EMR onboarding education in 2018 (pre-implementation) compared with 2019 (post-implementation). An additional four questions were asked in the post-implementation survey. All questions employed a Likert scale (1–5) with an opportunity for free-text. Raw data were used to calculate averages, standard deviations and the student t-test was used to compare the two cohorts where applicable. Results There were a total of 98 respondents in 2018 (pre-implementation) and 119 in 2019 (post-implementation). Satisfaction increased from 3.8/5 to 4.5/5 (p < 0.0001) following implementation of a peer-delivered curriculum in line with adult learning practices. The highest-rated factors were being taught by other doctors (4.9/5) and doctors having the appropriate knowledge to deliver training (4.9/5). Ninety-two percent of junior doctors were motivated to engage in further EMR education and 90% felt classroom support was adequate. Conclusion EMR onboarding education for medical users is a critical ingredient to organizational safety and efficiency. An improvement in satisfaction ratings by junior doctors was demonstrated after significant re-design of the curriculum was informed and delivered by peers, in line with adult learning principles.

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.

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