scholarly journals Designing and Evaluation of a Professional Iranian Software Package for Electronic Medical Record Documentation of Patients Referred to Periodontics Departments

2018 ◽  
Vol 9 (1) ◽  
pp. 1-6
Author(s):  
Jaber Yaghini ◽  
Ania Aminzadeh ◽  
Ahmad Moghareh Abed ◽  
Alireza Saeidi ◽  
Narges Naghsh
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Patient Information ◽  
Medical Records ◽  
Software Package ◽  
Advanced Search ◽  
Dental Records ◽  
Reduced Time ◽  
Medical Record Documentation

Background. This project aimed to design, develop and evaluate an integrated professional software package for filing the medical records of patients referred to periodontics departments. The software was intended to provide a range of features, including the availability of voice commands and retrieval of patient information based on different indices and characteristics. Methods. The overall percentage of satisfaction with the software was 90%. Moreover, 86.66% of the respondents preferred digital dental records to conventional records. Satisfaction in the reduced time of information registration and the advanced search options and availability of voice commands were 84% and 100%, respectively. Results. The overall percentage of satisfaction with the software was 90%. Moreover, 86.66% of the respondents preferred digital dental records to conventional records. Satisfaction in the reduced time of information registration and the advanced search options and availability of voice commands were 84% and 100%, respectively. Conclusion. According to the users' opinions, different features of the software, availability of voice commands and advanced search options, facilitated its use and decreased the timerequired for filing medical records. These features increased the users’ interest in the software

Selected Impressions on the Beginning of the Electronic Medical Record and Patient Information

2004 ◽  
Vol 43 (05) ◽  
pp. 537-542 ◽  
Author(s):  
R. Klar
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Patient Information ◽  
Medical Records ◽  
Data Set ◽  
The 1960S ◽  
User Friendly ◽  
Support Evaluation

Summary Objectives: To present an overview of early European and American work on Electronic Medical Records and patient information. Method: The invited lectures of “pioneers of electronic patient information” given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed. Results: The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first com-puterized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency. Conclusions: Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.

scholarly journals How to protect information from the Patient's electronic medical record: proposed mechanisms

2020 ◽  
Author(s):  
Odirlei Antonio Magnagnagno ◽  
Edimara Mezzomo Luciano ◽  
Rafael Mendes Lübeck
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Patient Information ◽  
Document Analysis ◽  
Information Privacy ◽  
Research Strategy ◽  
Structured Interviews ◽  
Normative Documents ◽  
Health Area

The purpose of this article is to identify mechanisms that may contribute to preserving the privacy of patient information contained in the electronic medical record. The research strategy is exploratory-descriptive, using Document Analysis and Case Study. A set of 20 documents, related to laws, manuals and standards, was analyzed and conducted case studies in two hospitals, preceded by a pilot case study. The cases were studied through semi-structured interviews, analysis of internal documents and occasional observation. In one of the stages of the research we have identification and analysis of regulatory and normative documents. And as a final result, the identification of the mechanisms that the hospitals surveyed use for information privacy. The most used mechanisms are those of processes in relation to the safeguard and those of relationship in relation to the awareness of the collaborators. As contribution, the article shows the need to strengthen the discussion of the theme for the academy. As well, a list of documents and mainly a list of mechanisms that can contribute to the protection of the information in the health area.

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.

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

scholarly journals Completeness criteria and filling of medical records in dental clinic of Cianjur General Hospital (January - April 2011)

2012 ◽  
Vol 24 (2) ◽  
Author(s):  
Annisa Rosalina ◽  
Netty Suryanti ◽  
Riana Wardani
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Sampling Technique ◽  
Patient Treatment ◽  
Dental Clinic ◽  
The Republic ◽  
Descriptive Method ◽  
Medical Record Documentation

Introduction: The medical record documentation of patient treatment Provides the which in turn, must be maintained Clearly, concisely, comprehensively and accurately. Medical record and its filling criteria must be based on the regulation of the Minister of Health of The Republic of Indonesia No. 269/Menkes/Per/III / 2008 regarding to the medical record. The research was Aimed to unveil the completeness of both criteria and filling on medical records at the General Hospital’s Dental Polyclinic of Cianjur District. Methods: Survey-based descriptive method was applied within the research. Its Data was acquired through the examination on medical records and interviews. Random sampling was conducted to run the sampling technique. 89 pieces of outpatient’s medical records were embodied as samples. Results: Based on the research results, it is discovered that 6 out of 12 criteria (50%) are not listed within the medical record. Thus, the filling on medical records of 100% is found incomplete. Conclusion: Medical records Dental Clinic Regional General Hospital Cianjur according to standards Permenkes No. 269/2008 not inlude on complete criteria according to standards Permenkes No. 269/2008.

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

scholarly journals P232 Assessing effectiveness and patient perceptions of a novel electronic medical record for the management of inflammatory bowel disease

2021 ◽  
Vol 15 (Supplement_1) ◽  
pp. S281-S281
Author(s):  
P Kaazan ◽  
T Li ◽  
W Seow ◽  
J Bednarz ◽  
J Pipicella ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Chronic Disease ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Data Capture ◽  
Patient Portal ◽  
Specific Data ◽  
Qualitative Feedback ◽  
Inflammatory Bowel

Abstract Background There is an increasing prevalence of chronic disease worldwide, resulting in multiple management challenges. Inflammatory bowel disease (IBD) is an exemplar chronic disease requiring optimal longitudinal coordinated care. We propose that Crohn’s Colitis Care (CCCare), a novel IBD-specific electronic medical record intended to improve IBD care is effective and acceptable to patients. We aimed to assess both the effectiveness of CCCare for data capture and patients’ acceptability of CCCare. Methods Methods: The study was conducted at two tertiary Australian hospitals with dedicated IBD services: Royal Adelaide Hospital and Liverpool Hospital. The effectiveness of CCCare was examined by comparing IBD-specific data completeness between pre-existing medical records and CCCare. Acceptability was assessed with quantitative and qualitative feedback through the CCCare patient portal and with standardized paper-based questionnaires administered to a convenience sample of IBD clinic patients in two unmatched pre-CCCare and post-CCCare exposure cohorts. Descriptive statistics and multivariable regression models were applied to specifically examine overall ratings of CCCare acceptability using a 10-point numeric scale; factors associated with acceptability before exposure to the system and whether exposure or security concerns influenced its acceptability. Results In all 73 cases reviewed, there was data gain when using structured CCCare fields compared to IBD documentation in usual medical records. Acceptability assessment through the patient portal feedback of 287 patients showed that the majority were very likely to recommend it to others (score, 8.56 ± 2.2 on a scale of 0–10). Common themes of concern among the 22 respondents with qualitative feedback were related to the novelty and limited experience of CCCare. Study questionnaires indicated that the overall acceptability in the combined cohort (n=310) was very high (8.4 ± 2.1; scale of zero to ten) with more than three-quarters of patients rating acceptability as at least 8 out of 10. Self-reported information technology (IT) literacy was positively associated with acceptability. Exposure had a small positive affect on acceptability while the level security concerns had little impact on acceptability. Conclusion The IBD-specific electronic medical record CCCare is effective in facilitating enhanced completeness of IBD-specific data capture in comparison to pre-existing medical records. It is highly acceptable to patients, especially those with reasonable IT literacy. Patient concerns about privacy and security of EMRs did not significantly influence acceptability.

scholarly journals Diabetes Risk Data Mining Method Based on Electronic Medical Record Analysis

2021 ◽  
Vol 2021 ◽  
pp. 1-11
Author(s):  
Yang Liu ◽  
Zhaoxiang Yu ◽  
Yunlong Yang
Keyword(s):  
Data Mining ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Diabetes Risk ◽  
Mining Method ◽  
Training Set ◽  
Medical Field ◽  
Data Mining Method

In today’s society, the development of information technology is very rapid, and the transmission and sharing of information has become a development trend. The results of data analysis and research are gradually applied to various fields of social development, structured analysis, and research. Data mining of electronic medical records in the medical field is gradually valued by researchers and has become a major work in the medical field. In the course of clinical treatment, electronic medical records are edited, including all personal health and treatment information. This paper mainly introduces the research of diabetes risk data mining method based on electronic medical record analysis and intends to provide some ideas and directions for the research of diabetes risk data mining method. This paper proposes a research strategy of diabetes risk data mining method based on electronic medical record analysis, including data mining and classification rule mining based on electronic medical record analysis, which are used in the research experiment of diabetes risk data mining method based on electronic medical record analysis. The experimental results in this paper show that the average prediction accuracy of the decision tree is 91.21%, and the results of the training set and the test set are similar, indicating that there is no overfitting of the training set.

scholarly journals The Implementation of Electronic Medical Record (EMR) in The Development Health Care System in Indonesia

2021 ◽  
Vol 4 (3) ◽  
Author(s):  
Nuke Amalia ◽  
Muh Zul Azhri Rustam ◽  
Anna Rosarini ◽  
Dina Ribka Wijayanti ◽  
Maya Ayu Riestiyowati
Keyword(s):  
Health Care ◽  
Information Technology ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Sector ◽  
Developed Countries ◽  
The United States ◽  
Long Time ◽  
The Cost

The development of information technology is now growing rapidly, including in the health sector. According to WHO, medical record is an important compilation of facts about a patient's life and health. The development of information technology in medical records is the electronic medical record (EMR). Developed countries, such as the United States and Korea have implemented EMR for a long time. In developing countries such as Indonesia, the development of EMR is still in progress because its implementation requires many factors to build a system or replace from manual medical records. Eventually, it is hoped that in the future all health care will use the EMR to resume patient datas from admission to discharge. The purpose of this study is to analyse the implementation and preparation of EMR in health care in Indonesia. This study is a literature review on the implementation and preparation of EMR in health care in Indonesia. The review is dome from 28 literature sources (Google-Scholar database). Total of 8 articles were obtained from 2017 to 2021. The results show that there are benefits after switching to EMR, even though some health care only used EMR in certain units. The highest benefit is reducing the cost of duplicating paper for printing. Also there is still limited human resources and tools for implementing EMR in Indonesia. The implementation of this EMR will enable the improvements of the service quality of the health care itself, especially in Indonesia.

scholarly journals ELECTRONIC MEDICAL RECORD AT RSIGM SULTAN AGUNG SEMARANG REVIEWED FROM THE COMPLETENESS AND THE SAFETY FORMAT SYSTEM

Jurnal Medali ◽  
2021 ◽  
Vol 3 (1) ◽  
pp. 20
Author(s):  
Adam Reza Pahlevi ◽  
Erdianto Setya Wardhana ◽  
Erna Dwi Agustin
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Inclusion Criteria ◽  
Health Ministry ◽  
Cross Sectional ◽  
Electronic Signature ◽  
Informed Consent Form ◽  
The Subject

Background: An electronic medical record is a medical system that can be used to store information about the track of a patient`s health. The completeness format of Electronic Medical Record used the format of Electronic Medical Record Guidance from Health Ministry Year 2015. The safety of electronic medical records has 6 aspects as follows privacy, integrity, authenticity, availability, access, control, non-rapadiatum.Method: This research aimed to know the description of the completeness format and the safety of The Electronic Medical Record at RSIGM Sultan Agung Semarang. This research used descriptive observational using a cross-sectional method. The subject of this study was Electronic Medical Records in March 2020. The samples were selected according to the inclusion criteria obtained from RSIGM Sultan Agung SemarangResult: The result of this research was used to know the description of the completeness of Electronic Medical Record Format and the safety of Electronic Medical Record at RSIGM Sultan Agung Semarang.Conclusion: The conclusion of this research showed Electronic Medical Record had been applied at RSIGM Sultan Agung Semarang but there are still lack in the informed consent form and the informed refusal, the safety of the electronic medical record was still lack in the electronic signature format.

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