Reducing risk and improving quality of patient care in hospital: the contribution of standardized medical records

Clinical Risk ◽  
2009 ◽  
Vol 15 (5) ◽  
pp. 183-187 ◽  
Author(s):  
Mala Bridgelal Ram ◽  
Iain Carpenter ◽  
John Williams
Keyword(s):  
Hospital Admission ◽  
Patient Care ◽  
Medical Record ◽  
Royal College ◽  
Medical Records ◽  
Health Informatics ◽  
National Standards ◽  
Electronic Environment ◽  
Quality Of Patient Care

This paper addresses a range of factors in relation to the medical record and reports on a project led by the Health Informatics Unit of the Royal College of Physicians of London. It includes discussion on the need to improve the quality of the information documented, the benefits of standardizing the medical record and describes a recently completed project developing national standards for structure and content of hospital admission records, and handover and discharge documentation. It does not address the implementation of these standards in an electronic environment.

scholarly journals Study of Sharing Patient Information by Nurses Between Inpatient and Outpatient Wards in Japan

2021 ◽  
Author(s):  
Natsuko Nishida ◽  
Tomoko Hikita ◽  
Megumi Iida ◽  
Goshiro Yamamoto ◽  
Tomohiro Kuroda
Keyword(s):  
Patient Care ◽  
Information Sharing ◽  
Patient Information ◽  
Medical Records ◽  
Communication Tool ◽  
Nursing Diagnosis ◽  
Quality Of Patient Care ◽  
Hospital Stays ◽  
Communication Needs

Shortening hospital stays increases communication needs between nurses in inpatient and outpatient wards. Smooth information sharing is required to reduce the workload of nurses and improve the quality of patient care. However, electronic medical records (EMR) system does not have sufficient functions to support information sharing between wards, because EMR has been developed mainly for recording. This study led to three improvements; unified communication tool, common patient list linked to EMR, and outpatient nursing diagnosis.

scholarly journals Auditing Orthopaedic Audit

2008 ◽  
Vol 90 (8) ◽  
pp. 675-678 ◽  
Author(s):  
E Guryel ◽  
K Acton ◽  
S Patel
Keyword(s):  
Patient Care ◽  
Medical Training ◽  
Action Plan ◽  
National Standards ◽  
Junior Doctors ◽  
Audit Process ◽  
Quality Of Patient Care ◽  
Audit Cycle ◽  
The Uk

INTRODUCTION Clinical audit plays an important role in the drive to improve the quality of patient care and thus forms a cornerstone of clinical governance. Assurance that the quality of patient care has improved requires completion of the audit cycle. A considerable sum of money and time has been spent establishing audit activity in the UK. Failure to close the loop undermines the effectiveness of the audit process and wastes resources. PATIENTS AND METHODS We analysed the effectiveness of audit in trauma and orthopaedics at a local hospital by comparing audit projects completed over a 6-year period to criteria set out in the NHS National Audit and Governance report. RESULTS Of the 25 audits performed since 1999, half were presented to the relevant parties and only 20% completed the audit cycle. Only two of these were audits against national standards and 28% were not based on any standards at all. Only a third of the audits led by junior doctors resulted in implementation of their action plan compared to 75% implementation for consultant-led and 67% for nurse-led audits. CONCLUSIONS A remarkably large proportion of audits included in this analysis failed to meet accepted criteria for effective audit. Audits completed by junior doctors were found to be the least likely to complete the cycle. This may relate to the lack of continuity in modern medical training and little incentive to complete the cycle. Supervision by permanent medical staff, principally consultants, and involvement of the audit department may play the biggest role in improving implementation of change.

494 Streamlining the Minor Operations Process - The Effect of Better Documentation

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
T Schrire ◽  
C Estela
Keyword(s):  
Patient Care ◽  
Plastic Surgery ◽  
Patient Experience ◽  
Patient Flow ◽  
Vital Part ◽  
Rapid Turnover ◽  
Quality Of Patient Care ◽  
New Form ◽  
Minor Operations

Abstract Introduction Plastic Surgery Minor Operations is a fast paced, rapid turnover operative environment. It is reliant on effective communication, accurate surgery, and time efficiency. It was noticed in our department that there was confusion regarding booking and operative intentions leading to delays in surgery and over-running lists. This was worsening patient experience and leading to delays in patient care. Method In response to the delays and confusion in booking, a new booking form was created, so all patients have a standardised booking containing the necessary information. This form was disseminated across all the booking clinics and formed a vital part of the pre-operative check in process. Results The audit was carried out at the time of introduction, and then re-audited a year later to see if the form has improved care for patients. Results showed that with the new booking form, people were not having to cancel or rearrange patients. Patient booking forms were sufficient, and a copy of the clinic letter no longer required for the operation to proceed or for clarity. It was noted that more senior advice was sought. Conclusions The new form has improved patient flow and quality of patient care, whilst streamlining the booking process.

scholarly journals Pediatric Endocrinology in the Time of COVID-19: Considerations for the Rapid Implementation of Telemedicine and Management of Pediatric Endocrine Conditions

2020 ◽  
Vol 93 (6) ◽  
pp. 343-350
Author(s):  
Molly O. Regelmann ◽  
Rushika Conroy ◽  
Evgenia Gourgari ◽  
Anshu Gupta ◽  
Ines Guttmann-Bauman ◽  
...  
Keyword(s):  
Patient Care ◽  
Care Patient ◽  
The Novel ◽  
Patient Privacy ◽  
Pediatric Endocrinology ◽  
Quality Of Patient Care ◽  
Care Outcomes ◽  
Novel Coronavirus ◽  
The Impact

<b><i>Background:</i></b> Pediatric endocrine practices had to rapidly transition to telemedicine care at the onset of the novel coronavirus disease 2019 (COVID-19) pandemic. For many, it was an abrupt introduction to providing virtual healthcare, with concerns related to quality of patient care, patient privacy, productivity, and compensation, as workflows had to change. <b><i>Summary:</i></b> The review summarizes the common adaptations for telemedicine during the pandemic with respect to the practice of pediatric endocrinology and discusses the benefits and potential barriers to telemedicine. <b><i>Key Messages:</i></b> With adjustments to practice, telemedicine has allowed providers to deliver care to their patients during the COVID-19 pandemic. The broader implementation of telemedicine in pediatric endocrinology practice has the potential for expanding patient access. Research assessing the impact of telemedicine on patient care outcomes in those with pediatric endocrinology conditions will be necessary to justify its continued use beyond the COVID-19 pandemic.

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