Abstract P118: Process Improvement for Stroke/EMS Run Sheets Available in Medical Record

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Tammy Watts
Keyword(s):  
Medical Record ◽  
Process Improvement ◽  
Medical Records ◽  
Automated System ◽  
Stroke Patients ◽  
Medical Record Number ◽  
Face To Face ◽  
Stroke Team ◽  
New Process ◽  
Automated Process

Background and Purpose: When stroke patients arrive to the hospital, it is imperative to have a clear picture of what occurred during transport from home, scene or other facility. The stroke team encountered difficulties in obtaining emergency medical services (EMS) run sheets in real time. We also found that these records, even when obtained, were often not scanned into the electronic medical record (EMR). Methods: We created a plan of action with our ED Stroke Champions, which involved development of an automated system to streamline the process of the run sheet scanning into EMR. In December 2019 barcode scanning devices were purchased and placed in the ED to facilitate this process. Ongoing education of the new process was conducted via email to notify our EMS partners of these changes, as well as face to face discussions whenever possible. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED. The process was that the EMS partners would:•receive the patient’s medical record number with barcode•stop at a central scanner•send the EMS run sheet directly into the EMR This process began on December 16, 2019. Three days before, another email went out to all EMS partners describing the process with a visual aide. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED. Results: In November 2019, 20 eligible ground EMS run sheets were sent to the Medical Records department for EMR scanning. After review, 13 (65%) were found scanned into the EMR. A review of January-July 2020 showed the following eligible scanned run sheets into EMR.•January 2020, 1 out of 21 (4.5%)•February 2020, 4 out of 26 (1.5%)•March 2020, 2 out of 17 (12%)•April 2020, 5 out of 15 (33%)•May 2020, 12 out of 18 (67%)•June 2020, 7 out of 7 (100%) Conclusions: With implementation of an automated process, significant improvement has been seen in obtaining and scanning run sheets. This will lead to better decision making regarding acute treatments in stroke patients.

Abstract T P260: Confirmation: The Target Stroke Best Practice Strategies Work

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Nojan Valadi ◽  
Alexis Thomas
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Process Improvement ◽  
Best Practice ◽  
Stroke Patients ◽  
High Performers ◽  
Process Implementation ◽  
Honor Roll ◽  
Stroke Team ◽  
Stroke Center

Background: A recent national push for optimizing stroke center performance led by the efforts of AHA/ASA to recognize high performers with the Target Stroke Honor Roll recognition have focused on achieving expedited treatment for stroke with door-to-needle (DTN) time of ≤60 minutes.Our organization recognized the need to optimize our performance and set an initial goal of achieving DTN time of ≤60 minutes in greater than 50% of our patients. The Target Stroke Initiative by the AHA/ASA identified 10 key strategies for best practice associated with reducing DTN times. Our organization adopted and implemented all of these strategies over a 30-day period. Methods: The Target Stroke best practice strategies were implemented over a 30-day period, and the Stroke Team worked collaboratively to identify other weaknesses needing to be addressed. DTN times ≤60 minutes from the 12 months prior to process improvement implementation were compared with the first 2 months post implementation. Results: There were 345 ischemic stroke patients treated at our facility during the 12 month period prior to the process implementation, with a total of 14 patients (1.12 per month) treated with tPA. The percentage of patients treated with tPA was 4%, and the percentage of patients treated with DTN ≤60 minutes was 0%. Over the two months following process implementation, 68 ischemic stroke patients were treated at our facility, with 11 patients treated with tPA (5.5 per month). The percentage of stroke patients treated with tPA was 16%, with 70% of patients treated with DTN ≤60 minutes. Conclusion: This study serves as confirmation that collaboration and implementation of the 10 key strategies for best practice as outlined by the Target Stroke Initiative, coupled with changes to identified areas of weakness, can improve and expedite the care of patients with acute ischemic stroke. This can substantially improve DTN times, as well as the overall number and percentage of patients that receive thrombolysis with a hopeful impact on their outcome as well as Target Stroke Honor Roll recognition for the facility. In conclusion, we recommend implementation of these best practice strategies to other facilities.

Abstract P270: Automating Processes to Expedite Medical Record Review in Research

2011 ◽  
Vol 4 (suppl_1) ◽  
Author(s):  
K M Reeder ◽  
Edward Ellerbeck ◽  
Marilyn Werkowitch ◽  
N. Nazir ◽  
B. Waltrip ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Emergency Room ◽  
Medical Record ◽  
Medical Records ◽  
Chart Review ◽  
Medical Record Review ◽  
Automated System ◽  
Emergency Room Visits ◽  
Automated Method ◽  
Record Review

Problem. Heart failure (HF) clinical trials often use medical record review data to determine HF related hospital events, such as emergency room visits and readmissions. However, reviewing medical records for each hospital event can be daunting. The purpose of this project was to expedite medical record review processes using an automated method for identifying potential HF related hospital events. Methods. A stepwise procedure was developed for obtaining electronic information of all consented HF clinical trial participants' hospital events. First, an electronic list of all study participants was generated from a study data base and electronically sent to the Medical Records department each month. Next, a list of all emergency room visits and hospitalizations, including admission and discharge dates, discharge disposition, and diagnosis and procedure codes was electronically generated by the Medical Records department. A trained cardiovascular research nurse reviewed the abstracted coding and billing data for each hospital event and identified specific codes potentially related to HF. Last, hospital events identified as meeting specific criteria were included in the medical record review. Results. Using the automated system, a total of 294 hospital events for 125 subjects were obtained from the Medical Records department during the initial 2 years of the clinical trial. Of these, 85 (29%) hospital events were identified as needing to undergo chart review. Thirty-three (39%) of the 85 charts that underwent blinded review were identified as being HF related hospital events. Conclusions. Automating procedures for obtaining hospital event information expedited both the systematic data review and chart review processes. In this study, combined use of automated processes for obtaining hospital event data and nurse review reduced the number of charts requiring blinded review by nearly 60%.

A retrospective analysis of medical record use in e-consultations

2016 ◽  
Vol 23 (5) ◽  
pp. 544-549 ◽  
Author(s):  
Jennifer L Pecina ◽  
Frederick North
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Medical Data ◽  
Academic Medical Centre ◽  
Face To Face ◽  
Clinical Notes ◽  
Academic Medical ◽  
Imaging Results ◽  
One Year ◽  
Time Frames

Introduction Under certain circumstances, e-consultations can substitute for a face-to-face consultation. A basic requirement for a successful e-consultation is that the e-consultant has access to important medical history and exam findings along with laboratory and imaging results. Knowing just what information the specialist needs to complete an e-consultation is a major challenge. This paper examines differences between specialties in their need for past information from laboratory, imaging and clinical notes. Methods This is a retrospective study of patients who had an internal e-consultation performed at an academic medical centre. We reviewed a random sample of e-consultations that occurred in the first half of 2013 for the indication for the e-consultation and whether the e-consultant reviewed data in the medical record that was older than one year to perform the e-consultation. Results Out of 3008 total e-consultations we reviewed 360 (12%) randomly selected e-consultations from 12 specialties. Questions on management (35.8%), image results (27.2%) and laboratory results (25%) were the three most common indications for e-consultation. E-consultants reviewed medical records in existence more than one year prior to the e-consultation 146 (40.6%) of the time with e-consultants in the specialties of endocrinology, haematology and rheumatology, reviewing records older than one year more than half the time. Labs (20.3%), office notes (20%) and imaging (17.8%) were the types of medical data older than one year that were reviewed the most frequently overall. Discussion Management questions appear to be the most common reason for e-consultation. E-consultants frequently reviewed historical medical data that is older than one year at the time of the e-consultation, especially in endocrinology, haematology and rheumatology specialties. Practices engaging in e-consultations that require transfer of data may want to include longer time frames of historical information for those specialties.

scholarly journals FAKTOR-FAKTOR YANG MEMPENGARUHI DUPLIKASI PENOMORAN BERKAS REKAM MEDIS DI RUMAH SAKIT ADVENT MEDAN

2020 ◽  
Vol 5 (1) ◽  
pp. 98-107
Author(s):  
Siti Agus Kartini
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Statistical Tests ◽  
Total Sample ◽  
Record Management ◽  
Test Results ◽  
Medical Record Number ◽  
Cross Sectional ◽  
Knowledge And Attitude ◽  
Quantitative Descriptive

Abstrak Rekam medis adalah berisikan cactatan dan dokumen tentang idetitas pasien , pemeriksaan, pengobatan, tindakan, dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis adalah keteranan baik yang tertulis maupun yang terekam tentang identitas, anamases, pemeriksaan laboratorium, diagnosa, segala pelyanan dan tindakan medik yang di berikan kepada pasien. Penomoran berkas rekam medis yang baik merupakan salah satu kunci keberhsilan atau kebaikan suatu manajemen rekam medis dari suatu pelayanan kesehatan, tentunya didukung dengan sistem yang baik. Tujuan dari penelitian ini adalah untuk mengetahui faktor-faktor yang mempengaruhi duplikasi penomoran rekam medis di Rumah Sakit Advent Medan. Jenis penelitian ini adalah deskriptif kuantitatif dengan menggunakan metode cross sectional yang dilakukan di Rumah Sakit Advent Medan pada bulan juli 2018, Populasi dalam penelitian ini adalah 11 petugas rekam medis yang terdiri dari 7 orang petugas pendaftaran dan rawat jalan 4 orang petugas pendaftaran rawat inap, Sampel dalam penelitian ini Menggunakan  total sampel, instumen penelitian yang digunakan observasi dan kuisoner,  berdasarkan hasil penelitan yang dilakukan faktor yang mempengaruhi duplikasi nomor rekam medis mayoritas Pengetahuan diperoleh 54,5% dari 11 petugas rekam medis dan dengan hasil uji statistik diperoleh  p=0.015<0.05. sehingga Ho ditolak artinya adanya pengaruh antara pengetahuan petugas rekam medis dengan duplikasi penomoran di Rumah Sakit Advent Medan. Minoritas sikap diperoleh 63,6% dan dengan hasil uji statistik diperoleh p=0,545%<0.05 sehingga Ho diterima artinya tidak ada pengaruh antara sikap dengan duplikasi penomoran. Dari hasil uji    statistik antara pengetahuan dan sikap, terdapat pengaruh pengetahuan dengan duplikasi penomoaran di Rumah Sakit Advent, Sedangkan sikap tidak ada pengaruh dengan duplikasi penomoran di Rumah Sakit Advent. Diharapkan kepada Rumah Sakit untuk memberikan evaluasi atau pelatihan kepada petugas rekam medis dibagian pendaftaran secara berkesinambungan. Kata Kunci: Rekam medis, Faktor- faktor duplikasi No rekam medis, Sistem     penomoran Abstrack Medical record is containing records and documents about patient identity, examination, treatment, actions, and other services that have been provided to patients. Medical records are written and recorded safety regarding identities, anamases, laboratory tests, diagnoses, all services and medical actions given to patients. Numbering a good medical record file is one of the keys to the success or goodness of a medical record management of a health service, of course, supported by a good system. The purpose of this study was to determine the factors that influence the duplication of medical record numbering in Medan Adventist Hospital. This type of research is quantitative descriptive using a cross sectional method conducted at Medan Adventist Hospital in July 2018, the population in this study were 11 medical record officers consisting of 7 registration and outpatient officers 4 inpatient registration officers, samples in this study Using the total sample, the research instrument used observation and questionnaire, based on the results of research conducted by factors that influence the duplication of the majority medical record number . so Ho is rejected, meaning that there is an influence between the knowledge of the medical record officer with the numbering duplication in Medan Adventist Hospital. Minority attitudes were obtained 63.6% and with statistical test results obtained p = 0.545% <0.05 so that Ho was accepted meaning that there was no influence between attitude and numbering duplication. From the results of statistical tests between knowledge and attitude, there is an influence of knowledge with duplication of numbers in Adventist Hospitals, whereas attitude has no influence with duplication of numbers in Adventist Hospitals. It is expected that hospitals will provide evaluation or training to medical records officers in the registration section on an ongoing basis.

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

Automated system for work preparation of parts production by sheet stamping

2020 ◽  
pp. 108-114
Author(s):  
L.R. Kashapova ◽  
D.L. Pankratov ◽  
V.G. Shibakov
Keyword(s):  
Deformation Process ◽  
Automated System ◽  
Tool Performance ◽  
Sheet Stamping ◽  
Mechanical And Physical Properties ◽  
Preparation Stage ◽  
Process Reliability ◽  
Recurrent Defects ◽  
Automated Process ◽  
Reliability Performance

The procedure of automated process reliability evaluation is developed in order to prevent recurrent defects in parts manufactured by die stamping. The procedure is based on the analysis of such factors as part design, material, its mechanical and physical properties; equipment parameters, tool performance, etc. The list of reliability factors may vary according to type of operation as deformation process is different for each group of operations. The adjustment of stamping process reliability performance prevents any defects emerging during production of critical parts as early as the work preparation stage.

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.

ANALISIS PELAKSANAAN REKAM MEDIS DI RUMAH SAKIT IBU DAN ANAK (RSIA ) WIDIYANTI

2018 ◽  
Vol 11 (1) ◽  
Author(s):  
Fera Siska
Keyword(s):  
Qualitative Research ◽  
Data Analysis ◽  
Data Collection ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Depth Information ◽  
Operational Procedure ◽  
Patient Registration ◽  
Qualitative Research Design

ABSTRACTBackground : Medical record is one of the most important pillars that can not be considered trivial in a hospital, with the development of medical scienceCommon Purpose : To find in-depth information about the implementation of medical records at the hospital Widiyanti PalembangResearch Method : Qualitative research design with data collection techniques are conducted in triangulation, The data analysis is inductive, and the results of the study are emphasized more at the meaning than the generalization. The Research Results : the Implementation of medical records have been running but there is no medical record organization, the implementation of medical record activities done by rolling. Human Resources (HR) medical records should be placed specifically in the medical record along with clear tasks. Method of organizing medical record has been run although the result is not optimal, because Standard Operational Procedure (SOP) that made not socialized. Facilities and infrastructure that support the implementation of the medical record is good, marked by the existence of a special records archive medical records. Facilities and infrastructure such as chairs, desks, computers, patient registration books and outpatient registration and inpatient services are available, do not have budget funds for medical record implementation, especially by sending medical recruiter for trainingConclusion : Implementation of medical records have been running but not optimal.

Comparison of Prescription and Medical Records in Reflecting Patient Antihypertensive Drug Therapy

1994 ◽  
Vol 28 (1) ◽  
pp. 99-104 ◽  
Author(s):  
Dale B. Christensen ◽  
Barbara Williams ◽  
Harold I. Goldberg ◽  
Diane P. Martin ◽  
Ruth Engelberg ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Health Maintenance Organizations ◽  
Antihypertensive Drug Therapy ◽  
Antihypertensive Medications ◽  
Pharmacy Records ◽  
Health Maintenance ◽  
Computer Based ◽  
High Level ◽  
Level Of Agreement

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n=982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5–8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

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