Medical Record Keeping

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

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

Endoscopy ◽  
2006 ◽  
Vol 37 (12) ◽  
Author(s):  
D Debnath ◽  
M Hutcheson ◽  
JK Hussey
Keyword(s):  
Medical Record ◽  
Record Keeping

scholarly journals Medical Record Keeping in the Summer Camp Setting

2016 ◽  
Vol 07 (04) ◽  
pp. 1154-1167
Author(s):  
Jaycelyn Holland ◽  
Stuart Weinberg ◽  
S. Rosenbloom ◽  
Laura Kaufman
Keyword(s):  
Medical Record ◽  
Summer Camp ◽  
The United States ◽  
Summer Camps ◽  
Pediatric Care ◽  
Health Staff ◽  
Health Providers ◽  
Health Records ◽  
Record Keeping ◽  
Survey Responses

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.

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.

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

Medical record keeping during a mass casualty incident: Development of a disaster medical record

2019 ◽  
Vol 14 (1) ◽  
pp. 9-15
Author(s):  
Salomon Willem Koning, MD ◽  
Mark J. J. Haverkort, MD, PhD ◽  
Luke P. H. Leenen, MD, PhD, FACS
Keyword(s):  
Medical Record ◽  
Chart Review ◽  
Mass Casualty Incident ◽  
Mass Casualty ◽  
Major Incident ◽  
Fisher Exact Test ◽  
Daily Routine ◽  
Primary Survey ◽  
Record Keeping ◽  
Survey Form

Objective: Improve documentation during a mass casualty incident (MCI).Design: This is a retrospective chart review.Setting: This chart review was done in the Major Incident Hospital (MIH). The MIH is a highly prepared back-up hospital in the center of the Netherland that can be deployed in case of a major incident.Patients, participants: Until recently, the MIH used an extensive paper medical record: the hospital in special circumstances medical record (HSCMR). A concise primary survey form was developed and attached to the HSCMR, forming the pilot disaster medical record (pDMR). In this retrospective chart review, primary survey data documented in the HSCMR (during a MCI) were compared to the pDMR (during a drill exercise). Three triage categories were used: T1, immediate; T2, urgent; and T3, delayed.Main outcome: The MIH hypothesized that a dedicated, concise, and practical primary survey form could improve quantitative patient documentation during an MCI. Significant differences were tested with the chi square and Fisher exact test (p 0.05).Results: The pDMR was used significantly more often 61 percent vs 89 percent (p = 0.001), especially in T1 and T2 patients. Quantitative documentation in the pDMR improved significantly on airway, breathing, breathing frequency, saturation, circulation, heart rate, blood pressure, Glasgow Coma Score, exposure, and medication given but not in cervical spine and temperature. Conclusion: Significantly more primary survey forms were used and more data were documented using the pDMR, especially in the most critical patients. An MCI medical record should be simple and concise and should not deviate from daily routine.

scholarly journals Effectiveness and efficiency of training in digital healthcare packages: training doctors to use digital medical record keeping software

2017 ◽  
Vol 41 (5) ◽  
pp. 479 ◽  
Author(s):  
Nicola Benwell ◽  
Kathryn Hird ◽  
Nicholas Thomas ◽  
Erin Furness ◽  
Mark Fear ◽  
...  
Keyword(s):  
Medical Record ◽  
Information And Communications Technology ◽  
Junior Doctors ◽  
Record Keeping ◽  
Induction Program ◽  
Close Proximity ◽  
Actual Use ◽  
E Learning ◽  
Similar Accuracy ◽  
Practice Methods

Objective Fiona Stanley Hospital (FSH) is the first hospital in Western Australia to implement a digital medical record (BOSSnet, Core Medical Solutions, Australia). Formal training in the use of the digital medical record is provided to all staff as part of the induction program. The aim of the present study was to evaluate whether the current training program facilitates efficient and accurate use of the digital medical record in clinical practice. Methods Participants were selected from the cohort of junior doctors employed at FSH in 2015. An e-Learning package of clinically relevant tasks from the digital medical record was created and, along with a questionnaire, completed by participants on two separate occasions. The time taken to complete all tasks and the number of incorrect mouse clicks used to complete each task were recorded and used as measures of efficiency and accuracy respectively. Results Most participants used BOSSnet more than 10 times per day in their clinical roles and self-rated their baseline overall computer proficiency level as high. There was a significant increase in the self-rating of proficiency levels in successive tests. In addition, a significant improvement in both efficiency and accuracy for all participants was measured between the two tests. Interestingly, both groups ended up with similar accuracy on the second trial, despite the second group of participants starting with significantly poorer accuracy. Conclusions Overall, the greatest improvements in task performance followed daily ward-based experience using BOSSnet rather than formalised training. The greatest benefits of training were noted when training was delivered in close proximity to the onset of employment. What is known about the topic? Formalised training in the use of information and communications technology (ICT) is widespread in the health service. However, there is limited evidence to support the modes of learning typically used. Formalised training is often costly and there is little other than anecdotal evidence that currently supports its efficacy in the workplace. What does the paper add? Assessment of accuracy when using the BOSSnet system over time revealed that daily use rather than formalised training appeared to have the most impact on performance. Formalised training was rated poorly, and this appeared to correlate with time between training and use. The present study suggests that formalised training, if required, should be delivered close in time to actual use of the system to benefit end-users. The study also shows that daily experience is more effective than formalised training to improve accuracy. What are the implications for practitioners? Formalised training for ICT needs to be scheduled in close proximity to end-user use of the ICT. Current scheduling may be beneficial for ease of delivery, but unless it is delivered at a suitable time the benefits are minimal. Formalised training programs may not be critical for all staff and all staff improve with contextualised experience given time. Training may be better suited to optional rather than compulsory delivery programs with ongoing delivery to suit user schedules.

Application of the Weed System to Psychiatric Records

1972 ◽  
Vol 3 (2) ◽  
pp. 119-129 ◽  
Author(s):  
Richard L. Grant ◽  
Barry M. Maletzky
Keyword(s):  
Medical Education ◽  
Patient Care ◽  
General Hospital ◽  
Medical Record ◽  
Medical Schools ◽  
Medical Chart ◽  
Chart Audit ◽  
Record Keeping ◽  
Teaching Research ◽  
Practicing Physicians

The medical record is being called upon to play an increasingly important role in medical education and effective patient care. The Weed system of “problem-oriented” medical record-keeping can enhance the effectiveness of the medical chart for these purposes and also for the various goals of chart audit. There has been increasing acceptance and application of this system both in medical schools and by practicing physicians. The psychiatric record has been particularly lacking in consistent organization, clarity, accuracy and readability. We have combined, in our approach to psychiatric records in a general hospital, a strongly behavioral and social psychiatric perspective with the Weed system to provide a psychiatric record that is a usable and practical document for teaching, research, effective continued patient care, and medical and fiscal audit.

Sign in / Sign up

Export Citation Format

Share Document