scholarly journals Electronic protocol for clinical data collection in chronic visceral ischemia

2017 ◽  
Vol 16 (1) ◽  
pp. 35-42
Author(s):  
Adriana Buechner de Freitas Brandão ◽  
Jorge Rufino Ribas Timi ◽  
Osvaldo Malafaia
Keyword(s):  
Data Collection ◽  
Medical History ◽  
Clinical Data ◽  
Medical Records ◽  
Storage Capacity ◽  
Vascular Diseases ◽  
Electronic Record ◽  
Electronic Data Collection ◽  
Visceral Ischemia ◽  
High Information

Abstract Patients with vascular diseases present with a long medical history which makes for complex and confusing medical records. Electronic record systems have a large storage capacity and high information processing capabilities, and may therefore improve the quality and reliability of prospective clinical studies. In the present study, a theoretical framework for clinical data collection in chronic visceral ischemia was created containing 5706 items, organized into six major categories: medical history, physical examination, laboratory testing, diagnosis, treatment and outcome. The database was used to construct an electronic data collection protocol, which was uploaded into the Integrated Electronic Protocol System (Sistema Integrado de Protocolos Eletrônicos, SINPE©) and then used to perform retrospective collection and analysis of clinical data from 10 patients using the SINPE© analysis module.

Testing the health literacy of twenty Bangladeshi patients before and 5 months after they begin to access their GP electronic record

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X697133
Author(s):  
Richard Fitton ◽  
Amir Hannan ◽  
Ingrid Brindle ◽  
Shafia Begum ◽  
Sarwar Shah
Keyword(s):  
Health Literacy ◽  
Health Outcomes ◽  
Medical History ◽  
Medical Records ◽  
Practice Nurse ◽  
Electronic Record ◽  
Phone Calls ◽  
Before And After ◽  
Medical Histories ◽  
Memory Knowledge

BackgroundPatients with higher health literacy enjoy better health outcomes and are more compliant with treatment. Health literacy is a product of memory, reason and imagination. Patients who can access their records have potentially more memory (knowledge) and make less phone calls to and have less consultations with their GP, practice nurse, HCA and other professionals.AimThe study aims to measure the knowledge that twenty Bangladeshi patients with poor English have of their medical history before and after access to their electronic record.Method55% of patients at Thornley House have access to their medical records. A simple questionnaire was given to 20 Bangladeshi patients before and 5 months after access to their electronic record. The questionnaires recorded the patients’ knowledge of their medical histories. The scores of the completed before and after questionnaires were compared to see if record access had increased patients’ knowledge.ResultsFive patients completed before and after questionnaires. Each achieved a higher score after record access. The differences in scores for the five patients were 2, 5, 1, 10, and 1, respectively.ConclusionHealth literacy for patients is similar to medical literacy for doctors. It requires knowledge, skills and attitudes. We will see whether record access can increase knowledge. Further studies might measure whether that increased knowledge improves skills and attitudes.

Digital risk analysis of cardiovascular diseases: new opportunities for the patients

2008 ◽  
Vol 149 (15) ◽  
pp. 677-684 ◽  
Author(s):  
Csaba Arnold ◽  
Zoltán Englert ◽  
Csaba Szabadhegyi ◽  
Csaba Farsang
Keyword(s):  
Risk Factors ◽  
Cardiovascular Diseases ◽  
Risk Analysis ◽  
Effective Treatment ◽  
Medical History ◽  
Vascular Diseases ◽  
Coronary Risk ◽  
Risk Status ◽  
Long Period ◽  
Graphic Presentation

Authors constructed a software helping the prevention programme of coronary and vascular diseases as the classical risk factors are used for graphic presentation of coronary risk as compared to “normal” risk. By repeated estimation alterations in coronary risk status can be compared to previous ones and thereby help evaluating the changes. This programme is highlighted by the presentation of changes in coronary risk of a patient during a 4-year-long period of her medical history. It is also shown how graphic presentation of risk can support the more effective treatment and patient care.

The use of a Domain Ontology for the Management of Essential Hypertension (Preprint)

2020 ◽  
Author(s):  
Emma Chavez ◽  
Vanessa Perez ◽  
Angélica Urrutia
Keyword(s):  
Decision Making ◽  
Essential Hypertension ◽  
Medical History ◽  
Medical Records ◽  
Medical Training ◽  
Relevant Information ◽  
Domain Ontology ◽  
Free Text ◽  
Snomed Ct ◽  
History Of

BACKGROUND : Currently, hypertension is one of the diseases with greater risk of mortality in the world. Particularly in Chile, 90% of the population with this disease has idiopathic or essential hypertension. Essential hypertension is characterized by high blood pressure rates and it´s cause is unknown, which means that every patient might requires a different treatment, depending on their history and symptoms. Different data, such as history, symptoms, exams, etc., are generated for each patient suffering from the disease. This data is presented in the patient’s medical record, in no order, making it difficult to search for relevant information. Therefore, there is a need for a common, unified vocabulary of the terms that adequately represent the diseased, making searching within the domain more effective. OBJECTIVE The objective of this study is to develop a domain ontology for essential hypertension , therefore arranging the more significant data within the domain as tool for medical training or to support physicians’ decision making will be provided. METHODS The terms used for the ontology were extracted from the medical history of de-identified medical records, of patients with essential hypertension. The Snomed-CT’ collection of medical terms, and clinical guidelines to control the disease were also used. Methontology was used for the design, classes definition and their hierarchy, as well as relationships between concepts and instances. Three criteria were used to validate the ontology, which also helped to measure its quality. Tests were run with a dataset to verify that the tool was created according to the requirements. RESULTS An ontology of 310 instances classified into 37 classes was developed. From these, 4 super classes and 30 relationships were obtained. In the dataset tests, 100% correct and coherent answers were obtained for quality tests (3). CONCLUSIONS The development of this ontology provides a tool for physicians, specialists, and students, among others, that can be incorporated into clinical systems to support decision making regarding essential hypertension. Nevertheless, more instances should be incorporated into the ontology by carrying out further searched in the medical history or free text sections of the medical records of patients with this disease.

Experience of Coding Ambulatory Visits to Outpatient Clinics

1996 ◽  
Vol 26 (3) ◽  
pp. 141-144 ◽  
Author(s):  
K Gibson ◽  
J Ives ◽  
M Wilson ◽  
D Richardson
Keyword(s):  
Data Collection ◽  
Clinical Data ◽  
Discharge Summary ◽  
Tertiary Hospital ◽  
Outpatient Clinics

Clinical data for all current outpatients at a large tertiary hospital has been collected for analysis. Patient diagnoses for selected “key” clinics have been coded to ICD-9-CM standards. Methods to reduce the volume of coding required for such data collection are discussed, and include short-lists of codes, default assignment of diagnoses codes according to the nature of visit, and producing a “discharge” summary for outpatients, similar to that routinely produced for inpatients.

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.

The Early Identification of Beginning Stuttering I

1992 ◽  
Vol 1 (3) ◽  
pp. 43-53 ◽  
Author(s):  
Pearl A. Gordon ◽  
Harold L. Luper
Keyword(s):  
Data Collection ◽  
Young Children ◽  
Clinical Data ◽  
Early Identification ◽  
Future Research ◽  
Speech Language Pathologists ◽  
Companion Article

Speech-language pathologists often struggle with the differentiation of stuttering from normal disfluencies in young children. Differential diagnostic protocols are frequently used to aid clinicians in this complex clinical task. In this article the general format and criteria, clinical data collection procedures, documentation, and relative use of quantification in six protocols are examined and discussed. In a forthcoming companion article, we will discuss problems encountered with the use of differential diagnostic protocols and offer suggestions for future research and the use of these protocols.

scholarly journals Parents’ Assessment of Disability in Their Children With Down Syndrome

2020 ◽  
Vol 7 ◽  
pp. 2329048X2093424
Author(s):  
Guðrun Jákupsdóttir Egholm ◽  
Margrethe Bjerknes ◽  
Niels Ove Illum
Keyword(s):  
Down Syndrome ◽  
Clinical Data ◽  
Medical Records ◽  
Rasch Analysis ◽  
Total Population ◽  
International Classification ◽  
International Classification Of Functioning ◽  
Disability And Health ◽  
Children With Down Syndrome

Aim: To describe a population of children with Down syndrome and evaluate their parents’ assessment of disability. Methods: Medical records of a population of 80 children with Down syndrome aged 5 to 17 years were analyzed for genetic background and associated diagnoses. And 27 parents to their children agreed to assess disability by employing a set of 26 International Classification of Functioning, Disability and Health body function (b) codes and activity and participation (d) codes. Clinical data were gathered and analysis of parents’ assessment of disability using psychometric and Rasch analysis was performed. Results: Clinical data on 27 children assessed by their parents and 53 children not assessed had identical associated diagnoses. The 26 International Classification of Functioning, Disability and Health codes and qualifiers had a mean score of 2.67 (range 1.26-4.11) and corrected code-total correlations mean of 0.55 (range −1.17 to 0.82). Rasch analysis showed proper code MNSQ infit and outfit values with mean 1.03 and 1.06. Conclusion: Clinical data on 27 children assessed were similar to 53 children that were not evaluated. Parents’ assessment of the 27 children showed good psychometric and Rasch analysis properties. Similar results might be expected in the total population of 80 children.

Guidelines were developed for data collection from medical records for use in retrospective analyses

2005 ◽  
Vol 58 (3) ◽  
pp. 269-274 ◽  
Author(s):  
Angelique C.M. Jansen ◽  
Emily S. van Aalst-Cohen ◽  
Barbara A. Hutten ◽  
Harry R. Büller ◽  
John J.P. Kastelein ◽  
...  
Keyword(s):  
Data Collection ◽  
Medical Records

scholarly journals Analysis of erroneous data entries in paper based and electronic data collection

2019 ◽  
Author(s):  
Benedikt Ley ◽  
Komal Raj Rijal ◽  
Jutta Marfurt ◽  
Nabaraj Adhikari ◽  
Megha Banjara ◽  
...  
Keyword(s):  
Data Collection ◽  
Data Entry ◽  
Categorical Variables ◽  
Data Sets ◽  
Continuous Variables ◽  
Electronic Data ◽  
Suitable Alternative ◽  
Electronic Data Collection ◽  
Data Points ◽  
Time Variables

Abstract Objective: Electronic data collection (EDC) has become a suitable alternative to paper based data collection (PBDC) in biomedical research even in resource poor settings. During a survey in Nepal, data were collected using both systems and data entry errors compared between both methods. Collected data were checked for completeness, values outside of realistic ranges, internal logic and date variables for reasonable time frames. Variables were grouped into 5 categories and the number of discordant entries were compared between both systems, overall and per variable category. Results: Data from 52 variables collected from 358 participants were available. Discrepancies between both data sets were found in 12.6% of all entries (2352/18,616). Differences between data points were identified in 18.0% (643/3,580) of continuous variables, 15.8% of time variables (113/716), 13.0% of date variables (140/1,074), 12.0% of text variables (86/716), and 10.9% of categorical variables (1,370/12,530). Overall 64% (1,499/2,352) of all discrepancies were due to data omissions, 76.6% (1,148/1,499) of missing entries were among categorical data. Omissions in PBDC (n=1002) were twice as frequent as in EDC (n=497, p<0.001). Data omissions, specifically among categorical variables were identified as the greatest source of error. If designed accordingly, EDC can address this short fall effectively.

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