Quality of medical record keeping: significance difference between types of admissions

Endoscopy ◽  
2006 ◽  
Vol 37 (12) ◽  
Author(s):  
D Debnath ◽  
M Hutcheson ◽  
JK Hussey
Author(s):  
Nur Maimun ◽  
Jihan Natassa ◽  
Wen Via Trisna ◽  
Yeye Supriatin

The accuracy in administering the diagnosis code was the important matter for medical recorder, quality of data was the most important thing for health information management of medical recorder. This study aims to know the coder competency for accuracy and precision of using ICD 10 at X Hospital in Pekanbaru. This study was a qualitative method with case study implementation from five informan. The result show that medical personnel (doctor) have never received a training about coding, doctors writing that hard and difficult to read, failure for making diagnoses code or procedures, doctor used an usual abbreviations that are not standard, theres still an officer who are not understand about the nomenclature and mastering anatomy phatology, facilities and infrastructure were supported for accuracy and precision of the existing code. The errors of coding always happen because there is a human error. The accuracy and precision in coding very influence against the cost of INA CBGs, medical and the committee did most of the work in the case of severity level III, while medical record had a role in monitoring or evaluation of coding implementation. If there are resumes that is not clearly case mix team check file needed medical record the result the diagnoses or coding for conformity. Keywords: coder competency, accuracy and precision of coding, ICD 10


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.


2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A Ghareib ◽  
Z Vinnicombe ◽  
G Visser ◽  
A Ra ◽  
M Mantella ◽  
...  

Abstract Introduction St. George’s University Hospitals NHS Foundation Trust is a tertiary plastic surgery centre serving a population of 3.5 million in and around South West London. Telemedicine Referral Image Portal System (TRIPS) is integral to our service, allowing triage of patients in remote locations. During Covid, TRIPS helped in reducing footfall and streamlining out of hospital referrals to reduce unnecessary transfer. The aim of this project was to assess the quality of clinical documentation for emergency referrals to plastic surgery via TRIPS. Method We performed a retrospective review of all patients referred to plastic surgery via TRIPS during April 2020. Documentation standards were determined from national guidance. After introduction of a condensed guide, a second review was performed four months later. Results In April, 131 referrals were recorded on TRIPS. Only 22.9% of records met the standard. The most common omission was treatment advice. Following introduction of guidance, 215 TRIPS records were reviewed. The quality of clinical documentation improved in all aspects with a compliance rate of 89%. Conclusions Although TRIPS remains a useful tool for triage, it is a clinical document and must meet the standards of clinical record keeping. Introduction of clear guidelines improves overall compliance.


Itinerario ◽  
2020 ◽  
Vol 44 (3) ◽  
pp. 552-571
Author(s):  
Paolo Sartori

AbstractCui bono information and record keeping? In his most recent work devoted to the study of British and French imperialism in the Levant in early modern history, Cornel Zwierlein has argued that “empires are built on ignorance.” It is, of course, true that during the old regime Western knowledge of things “Oriental” was patently defective, marked as it was by blind spots and glaring gaps; and if observed in the broader context of European colonialism in Asia, the British and French cases are hardly exceptional. Sanjay Subrahmanyam's Europe's India has shown compellingly that the Portuguese, too, blindly forged ahead in their imperial expansion into South Asia, with a good dose of improvisation. By focusing on a mission to Khiva, Bukhara, and Balkh in 1732, I set out to show that the Russian venture in Asia too was premised upon ignorance, among other things. More specifically, I argue that diplomatic and commercial relations between Russia and Central Asia developed in parallel with the neglect of intelligence gathered and made available in imperial archives. Reflecting on the fact that the Russian enterprise in Asia was minimally dependent on information allows us to complicate the reductive equation of knowledge to power, which originates from the “archival turn.” Many today regard archives as reflective of projects of documentation, which granted epistemological virtue to the texts stored, ordered, and preserved therein. The archives generated truth claims, we are told, about hierarchies of knowledge produced by states and, by doing so, they effectively operated as a technological apparatus bolstering the state. However, not all the texts which we find in archives always retained their pristine epistemic force. To historicise the uses, misuses, and, more importantly, the practices of purposeful neglect of records invites us to revisit the quality of transregional connectivity across systems of signification in the early modern period.


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

2021 ◽  
pp. 5-12
Author(s):  
Latysheva N. A. ◽  

Judicial record-keeping, which in its content refers to judicial activity of a security, auxiliary nature, received an impetus for its development in connection with the amendments to the 1993 Constitution of the Russian Federation that entered into force on July 4, 2020. The introduction of innovations, which will take place through the organizational, guiding activities of the bodies of the judicial community – the Council of Judges of the Russian Federation and the bodies of the judicial community in the constituent entities of the Russian Federation and the improvement of regulatory regulation by authorized entities will allow realizing the needs of society in a new quality of relations between the judiciary and citizens of the Russian Federation. The article substantively defines the problems of the development of normative regulation in the course of ensuring arbitration proceedings, organizing constitutional and legal judicial statistics, exercising the rights of citizens to use the national language in the process of conducting judicial proceedings. In connection with the findings, options are proposed for generating ideas in the field of organizational support of justice.


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.


Author(s):  
Christian A. Klaus ◽  
Luis E. Carrasco ◽  
Daniel W. Goldberg ◽  
Kevin A. Henry ◽  
Recinda L. Sherman

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