Retention of Medical Records at Sydney Hospital

1987 ◽  
Vol 17 (4) ◽  
pp. 6-10 ◽  
Author(s):  
Barbara Reed
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Careful Consideration ◽  
Patient Records ◽  
A Priority ◽  
Retention Policies

Determining retention policies for the accumulated three and one half kilometres of patient records has become a priority at Sydney Hospital. This has involved a careful consideration of how the retention of a proportion of the total records can be reconciled to the function of the medical record. The techniques of culling, sampling and selection are discussed and an outline of the solution agreed at Sydney Hospital is given.

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

Rice tablet (Aluminum Phosphide) poisoning

2016 ◽  
Vol 5 (11) ◽  
pp. 5041
Author(s):  
Farkhondeh Jamshidi ◽  
Ahmad Ghorbani ◽  
Sina Darvishi*
Keyword(s):  
Medical Records ◽  
Statistical Tests ◽  
Patient Records ◽  
Demographic Information ◽  
Aluminum Phosphide ◽  
Men And Women ◽  
Significant Difference ◽  
The Mean ◽  
Aluminum Phosphide Poisoning ◽  
Commit Suicide

The abuse of some pesticides especially to suicide is one of the current problems of pesticides. Aluminum phosphide induced poisoning usually happens to suicide and sometimes it is due to accidental occupational exposure and in a few cases it has some criminal intensions. This study is conducted to evaluate patients poisoned with aluminum phosphide. In the present study the medical records of cases of poisoning with rice tablets (aluminum phosphide) hospitalized in Ahvaz Razi hospital is studied. Accordingly, a checklist is prepared that included demographic information of patients (age, gender) and information on patient records (information on poisoning) are completed using the patients’ medical records. The analysis of data is done by SPSS V22. 18 patients poisoned with rice tablet (aluminum phosphide) are studied. Results of the study show that 11 patients are male and seven are female. The mean patient age is 27.06 ±8.04 years that is 28 ±9 and 25 ±6.02 in men and women respectively. Statistical tests show no statistically significant difference in mean age in both genders (P> 0.05). Among patients, 11 subjects took aluminum phosphide to attempt suicide and 3 cases took it unintentionally and of course the reason is not mentioned in four cases. Among the patients who tried to commit suicide by taking aluminum phosphide, 6 cases are male and 5 cases are female that no statistically significant difference is observed between the genders in this respect (P> 0.05). In addition to the study of the complications caused by this poisoning and its mortality, it is recommended to responsible authorities to provide the necessary educations and treatments to prevent this type of poisoning.

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.

Writing Medical Records

1986 ◽  
Vol 16 (4) ◽  
pp. 331-341
Author(s):  
Michael P. Pagano ◽  
David Mair
Keyword(s):  
Medical Students ◽  
Medical Records ◽  
Medical Writing ◽  
Law School ◽  
Patient Records ◽  
Radiology Reports ◽  
Legal Implications ◽  
Composing Process ◽  
Medical Documents ◽  
School Faculty

A study was undertaken both to evaluate how medical students are taught to write patient records and to examine the writing done by doctors. Typical medical records, written by medical doctors, were also evaluated. A single questionnaire was sent to eighty-four medical school professors, twenty law school faculty, and five practicing attorneys. The questionnaire asked how medical records were used and what the legal implications were in authoring a patient record. The medical professionals were also asked how their schools taught medical writing. The questionnaire pointed out that most medical schools teach less than ten hours of medical writing in their curricula and that patient records are not written with an understanding of the various audiences, purposes, and uses for medical documents. Two radiology reports are discussed in terms of their clarity and usefulness for medical and extra-medical readers. The study concludes that medical students should be taught a composing process so that they will understand the audience, purpose, and use for the patient records they write.

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.

scholarly journals Could Personalised Self-Inking Stamps Improve Identification Standards in Medical Records?

2012 ◽  
Vol 94 (4) ◽  
pp. 128-130
Author(s):  
Sac MacKeith ◽  
Svelusamy ◽  
A Pajaniappane ◽  
P Jervis
Keyword(s):  
Medical Practice ◽  
Medical Records ◽  
General Medical Council ◽  
Case Note ◽  
Medical Council ◽  
Patient Records ◽  
Medical Case ◽  
Good Medical Practice ◽  
Professional Contact

Doctors' handwriting has long been criticised as being difficult to read or even illegible. In more recent years research has confirmed that it is not uncommon to find medical case note entries that are deficient, illegible or unidentifiable. In Good Medical Practice the General Medical Council (GMC) asks that doctors 'keep clear, accurate, legible and contemporaneous patient records'. In addition, the GMC 'expects that all doctors will use their reference numbers widely to identify themselves to all those with whom they have professional contact'. This includes encouragement for its use in case note entries and prescribing.

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.

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 QUANTITATIVE EVALUATION OF MEDICAL RECORD DOCUMENTATION IN IMAM REZA HOSPITAL, MASHHAD, IRAN

2017 ◽  
Vol 1 (4) ◽  
pp. 98-99
Author(s):  
Zahra Mazloum khorasani ◽  
Mahmood Tara ◽  
Kobra Etminani ◽  
Zohre Moosavi ◽  
Zahra Ebnehoseini
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Qualitative Evaluation ◽  
Cross Sectional Study ◽  
Diabetic Patients ◽  
Cross Sectional ◽  
Accurate Treatment ◽  
Diabetes Center ◽  
Data Elements ◽  
Medical Record Documentation

Introduction: Diabetes is the most common endocrine disease. Given the importance of medical record documentation for diabetic patients and its significant impact on accurate treatment process, as well as early diagnosis and treatment of acute and chronic complications, this study aimed to qualitatively evaluate medical record documentation of diabetic patients. Methods: This descriptive and cross-sectional study was conducted on all medical records of diabetic patients (1200 cases) in the comprehensive Diabetes Center of Imam Reza Hospital. A checklist was prepared according to the main sectors and their sub-data elements to conduct a qualitative evaluation on documentation of medical records of diabetic patients.  Descriptive statistics were used to report the results. Results: In this study, 1200 (710 women and 490 men) cases were evaluated. Mean documentation of main sectors of diabetic patients’ records were as follows: 49% demographic characteristics, 14% patient referral, 4% diagnosis, 50% lab tests, 25% diabetes medications,13% nephropathy screening test, 10% diabetic neuropathy, 41% specialty and subspecialty consultations and internal medicine physicians visits did not complete for all the patients. Conclusion: According to the results of this study, qualitative evaluation of medical record documentation of diabetic patients Showed poor documentation in this regard. It is suggested that results of this study be accessible to physicians of healthcare centers to take a positive step toward improved documentation of medical records. In addition, it seems necessary to modify diabetic medical records.

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