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.

scholarly journals IS PATIENT SAFETY AT THE HEART OF MEDICAL EDUCATION IN INDONESIA? REFLECTION ON THE IMPACT OF THE NATIONAL EXAMINATION

2019 ◽  
Vol 8 (3) ◽  
pp. 153
Author(s):  
Rachmadya Nur Hidayah
Keyword(s):  
Medical Education ◽  
Quality Assurance ◽  
Patient Safety ◽  
Focus Groups ◽  
Patient Care ◽  
Medical Schools ◽  
Theory Approach ◽  
High Stakes ◽  
Teachers And Students ◽  
The Impact

ABSTRACT Background: National examinations in Indonesia (UKMPPD) has been implemented since 2007 as a quality assurance method for medical graduates and medical schools. The impact of UKMPPD has been studied since then, where one of the consequences were related to how it affected medical education and curricula. This study explored the consequences of UKMPPD, focusing on how the students, teachers, and medical schools’ leaders relate the examination with patient care. This study aimed to explore the impact of UKMPPD on medical education, which focusing on the issue of patient safety. Methods: This study was part of a doctoral project, using a qualitative method with a modified grounded theory approach. The perspectives of multiple stakeholders on the impact of the UKMPPD were explored using interview and focus groups. Interviews were conducted with medical schools’ representatives (vice deans/ programme directors), while focus groups were conducted with teachers and students. A sampling framework was used by considering the characteristics of Indonesian medical schools based on region, accreditation status, and ownership (public/ private). Data was analysed using open coding and thematic framework as part of the iterative process. Results: The UKMPPD affected how the stakeholders viewed this high-stakes examination and the education delivered in their medical schools. One of the consequences revealed how stakeholders viewed the UKMPPD and its impact on patient care. Participants viewed the UKMPPD as a method of preparation for graduates’ real clinical practice. The lack of reference for patient safety as the impact of the UKMPPD in this study showed that there were missing links in how stakeholders perceived the examination as part of quality assurance in health care. Conclusion: The UKMPPD as a high-stakes examination has a powerful impact in changing educational policy and programmes in Indonesia. However, in Indonesia, the examination brought in the reflection on how the “patient” element was lacking from medical education. This research offers an insight on the concept of patient safety in Indonesia and how the stakeholders could approach the issue. Keywords: UKMPPD, national licensing examination, impact, competence, patient safety, curriculum 

scholarly journals Unmuting Medical Students’ Education: Utilizing Telemedicine During the COVID-19 Pandemic and Beyond (Preprint)

2020 ◽  
Author(s):  
Ariella Magen Iancu ◽  
Michael Thomas Kemp ◽  
Hasan Badre Alam
Keyword(s):  
Medical Education ◽  
Medical Students ◽  
Patient Care ◽  
Core Competencies ◽  
Medical Schools ◽  
High Quality ◽  
Social Distancing ◽  
Student Education

UNSTRUCTURED Due to the coronavirus disease (COVID-19) pandemic, medical schools have paused traditional clerkships, eliminating direct patient encounters from medical students’ education for the immediate future. Telemedicine offers opportunities in a variety of specialties that can augment student education during this time. The projected growth of telemedicine necessitates that students learn new skills to be effective providers. In this viewpoint, we delineate specific telehealth opportunities that teach core competencies for patient care, while also teaching telemedicine-specific skills. Schools can further augment student education through a variety of telemedicine initiatives across multiple medical fields. The explosion of telemedicine programs due to the pandemic can be a catalyst for schools to integrate telemedicine into their current curricula. The depth and variety of telemedicine opportunities allow schools to continue providing high-quality medical education while maintaining social distancing policies.

Technologic Advances in Neurologic Practice and Education

2018 ◽  
pp. 21-31
Author(s):  
Charles Donohoe ◽  
Sean M. Gratton ◽  
Vivek M. Vallurupalli ◽  
Steven D. Waldman
Keyword(s):  
Medical Education ◽  
Clinical Practice ◽  
Medical Students ◽  
Optic Nerve ◽  
Patient Care ◽  
Clinical Information ◽  
Fundus Photography ◽  
Retinal Vasculature ◽  
Ocular Fundus ◽  
Practicing Physicians

Although the visualization of the ocular fundus yields important clinical information regarding the optic nerve and retinal vasculature, proficiency in using the traditional handheld direct ophthalmoscope by both practicing physicians and medical students continues to deteriorate. A replacement for the direct ophthalmoscope is long overdue. The authors suggest a role for non-mydriatic fundus photography as having potential to resurrect the dying art of visualizing the fundus in both clinical practice and medical education. This chapter reviews the substantial barriers in both patient care as well as graduate and undergraduate medical education created by technical difficulties encountered using the direct ophthalmoscope to visualize the ocular fundus. The authors propose that a smartphone-compatible adaptor to view the ocular fundus will replace the direct ophthalmoscope.

A Question on Chart Audits

PEDIATRICS ◽  
1976 ◽  
Vol 57 (4) ◽  
pp. 575-575
Author(s):  
Helene S. Thorpe ◽  
James H. Thorpe
Keyword(s):  
Medical Education ◽  
Clinical Investigation ◽  
Third Party ◽  
Chart Audit ◽  
Record Keeping ◽  
Malpractice Claims ◽  
Long Time ◽  
Chart Audits ◽  
Third Party Reimbursement

Outpatient chart audit, as performed by Russo et al.'s faculty,1 demonstrates the problems of measurement as much as that which is measured. By now, with national emphasis on inpatient audit,2 it is evident that medical education and practice have neglected documentation of care given–this despite a long-time need for accurate, concise, legible record-keeping to assist in care by multiple professionals, to support disability evaluations, to avoid malpractice claims, to effect third-party reimbursement, and to enhance clinical investigation, among others.

scholarly journals Health informatics in UK Medical Education: an online survey of current practice

JRSM Open ◽  
2016 ◽  
Vol 8 (1) ◽  
pp. 205427041668267 ◽  
Author(s):  
Sarah Walpole ◽  
Paul Taylor ◽  
Amitava Banerjee
Keyword(s):  
Medical Education ◽  
Health Informatics ◽  
Online Survey ◽  
Medical Curriculum ◽  
Academic Staff ◽  
Medical Schools ◽  
Medical Council ◽  
National Guidelines ◽  
Record Keeping ◽  
Medical Undergraduate

Objective Health informatics has growing importance in clinical practice with successive General Medical Council recommendations. However, prior data suggest that undergraduate medical education largely neglects this area. An up-to-date, UK-wide view of health informatics training in medical schools is required. Design An online survey was developed using current guidance and recommendations of UK professional bodies. Participants and Setting Senior academic staff and health informatics educators at all 34 UK medical schools were invited to complete the survey. Main outcome measures Quantitative and qualitative data regarding health informatics in the undergraduate medical curriculum. Results A total of 26/34 (76%) of UK medical schools responded and 23 provided full information. Aspects most frequently mentioned were literature searching and research governance. Seventeen per cent of respondents felt there was little or no HI training, although clinical record keeping was addressed by all medical schools. Pedagogies used to teach health informatics were self-directed learning (78%) to lecture based (70%), seminars (70%), informal teaching in clinical settings (57%) and problem-based learning (22%). Health informatics was usually integrated vertically and horizontally across the curriculum (76%). Assessment and updates of the health informatics curriculum are limited (57 and 41%, respectively). Thirty-two per cent of respondents reported a low level of confidence among students to use health informatics as doctors. In the most up-to-date survey of health informatics teaching in UK medical schools, there are three major findings. First, the proportion of health informatics in the medical undergraduate curriculum is low. Second, there was variation in content, pedagogy and timing across medical schools. Third, health informatics is rarely assessed and course content is not regularly updated. Conclusions There is a role for national guidelines and further research in this area of the curriculum which is rapidly gaining in prominence.

scholarly journals Unmuting Medical Students’ Education: Utilizing Telemedicine During the COVID-19 Pandemic and Beyond

10.2196/19667 ◽  
2020 ◽  
Vol 22 (7) ◽  
pp. e19667 ◽  
Author(s):  
Ariella Magen Iancu ◽  
Michael Thomas Kemp ◽  
Hasan Badre Alam
Keyword(s):  
Medical Education ◽  
Medical Students ◽  
Patient Care ◽  
Core Competencies ◽  
Medical Schools ◽  
High Quality ◽  
Social Distancing ◽  
Student Education

Due to the coronavirus disease (COVID-19) pandemic, medical schools have paused traditional clerkships, eliminating direct patient encounters from medical students’ education for the immediate future. Telemedicine offers opportunities in a variety of specialties that can augment student education during this time. The projected growth of telemedicine necessitates that students learn new skills to be effective providers. In this viewpoint, we delineate specific telehealth opportunities that teach core competencies for patient care, while also teaching telemedicine-specific skills. Schools can further augment student education through a variety of telemedicine initiatives across multiple medical fields. The explosion of telemedicine programs due to the pandemic can be a catalyst for schools to integrate telemedicine into their current curricula. The depth and variety of telemedicine opportunities allow schools to continue providing high-quality medical education while maintaining social distancing policies.

Graduate Medical Education

1987 ◽  
Author(s):  
William G. Rothstein
Keyword(s):  
Medical Education ◽  
Medical School ◽  
Patient Care ◽  
Graduate Medical Education ◽  
General Medicine ◽  
Medical Specialty ◽  
Medical Schools ◽  
University Hospital ◽  
Graduate Medical ◽  
Interns And Residents

Graduate medical education has become as important as attendance at medical school in the training of physicians. Up to 1970, most graduates of medical schools first took an internship in general medicine and then a residency in a specialty. After 1970, practically all medical school graduates entered residency training in a specialty immediately after graduation. Residency programs have been located in hospitals affiliated with medical schools and have been accredited by specialty boards, which have been controlled by medical school faculty members. This situation has led to insufficient breadth of training and lax regulation of the programs. The internship, which followed graduation from medical school until its elimination after 1970, consisted of one or two years of hospital training, usually unconnected with any medical specialty. It was designed to provide gradually increasing responsibility for patient care, supplemented by formal teaching in rounds and seminars. In practice, as George Miller observed in 1963, it was “virtually impossible to find an internship [program with] a graded and sequential course of study leading to relatively well-defined goals.” This was also the finding of several surveys of interns and physicians. A 1959 survey of 2,616 interns found that the two most frequently cited deficiencies of internships were lack of “sufficient review and criticism of your work with patients,” cited by 47 percent, and “adequate instruction in the application of scientific knowledge to patient care,” cited by 34 percent. A 1952 survey of 6,662 graduates of the medical school classes of 1937 and 1947 and a later survey of over 3,000 interns and residents produced similar findings. Formal instruction during the internship was usually casual and unsystematic. Stephen Miller's study of one university hospital found that interns spent only a few hours per week in formal lectures and conferences and on rounds. In teaching on rounds, “the visiting physician does not prepare a lecture or other teaching material. He simply walks onto the ward and responds to patients and their problems with opinions and examples from his own clinical experience.” The educational value of rounds therefore depended on the illnesses of the patients and the relevant skills of the physicians.

Unintended consequences of the electronic medical record on physicians in training and their mentors

2018 ◽  
Vol 94 (1117) ◽  
pp. 659-661 ◽  
Author(s):  
Zachary R Paterick ◽  
Nachiket J Patel ◽  
Timothy Edward Paterick
Keyword(s):  
Medical Education ◽  
Medical Care ◽  
Patient Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Intelligent Systems ◽  
Clinical Medicine ◽  
Clinical Skills ◽  
Unintended Consequences ◽  
Cumulative Impact

For physicians in training and their mentors, the process of learning and teaching clinical medicine has become challenging in the electronic medical record (EMR) era. Trainees and their mentors exist in a milieu of incessant box checking and laborious documentation that has no clinical educational value, limits the time for teaching and curtails clinical cognitive skill development. These unintended consequences of the EMR are juxtaposed against the EMR’s intended benefits of improved patient care and safety with reduced medical errors, improved clinical support systems, reduced potential for negligence with clinical data and metadata data supporting compliance with the standard of care. Although the mindset was technology would be the solution to many healthcare issues, there was not an appreciation of the cumulative impact of the non-educational workload on physician time and education. The EMR was intended to improve the efficiency of medical care and time management. It appears that the unintended consequences of the EMR with numerous checkboxes, automatic filling of computer screens, pre-worded templates, and automatic history and physical examination functions with detailed administrative oversight and compliance monitoring were not appreciated, and many believe that burden has overwhelmed the intended benefits of the EMR. This juxtaposition of the intended and unintended consequences of the EMR has left trainees and mentors struggling to optimise medical education and development of clinical skills while providing high-quality patient medical care. Physician educators must identify how to use the benefits of the EMR and overcome the unintended consequences. A major unintended consequence of the EMR is time dedicated to automate functions that detract from the time spent with mentors and patients. This time loss has the potential to restrict the physician from meeting the essential canons of medical informed consent and interfere with a physician meeting her fiduciary duties to the patient. To raise awareness and stimulate a search for solutions that benefit medical education and patient care, we will explore the intended and unintended consequences of the EMR and potential solutions using the intelligent systems of the EMR.

Negative Impact of Computerized Record Keeping in a Psychiatric Department*

1983 ◽  
Vol 28 (2) ◽  
pp. 114-116 ◽  
Author(s):  
J.D. Mclean ◽  
I.A. Kapkin
Keyword(s):  
Patient Care ◽  
General Hospital ◽  
Negative Impact ◽  
Psychiatric Inpatient ◽  
Record Keeping ◽  
Rapid Deterioration ◽  
Preventative Measures ◽  
Psychiatric Department ◽  
Computerized System ◽  
Inpatient Department

A general hospital psychiatric inpatient department which had been regarded as efficient and effective in its functioning, underwent rapid deterioration after the introduction of a computerized system of charting and record keeping. The deterioration was attributed to: 1) Impeded communication among the staff; 2) Loss of time available for patient care; 3) Staff frustration with the system and subsequent feelings of anger and helplessness being communicated to the patients. The authors describe the development of this deterioration and discuss possible psychodynamic factors and suggested corrective-preventative measures.

Medical record keeping and system performance in orthopaedic trauma patients

2016 ◽  
Vol 40 (6) ◽  
pp. 619 ◽  
Author(s):  
Filip Cosic ◽  
Lara Kimmel ◽  
Elton Edwards
Keyword(s):  
Patient Care ◽  
Medical Record ◽  
Medical Records ◽  
System Performance ◽  
Junior Doctors ◽  
Orthopaedic Trauma ◽  
Lower Limb Injury ◽  
Record Keeping ◽  
Operative Report ◽  
Medical Record Documentation

Objective The medical record is critical for documentation and communication between healthcare professionals. The aim of the present study was to evaluate important aspects of the orthopaedic medical record and system performance to determine whether any deficiencies exist in these areas. Methods Review of 200 medical records of surgically treated traumatic lower limb injury patients was undertaken. The operative report, discharge summary and first and second outpatient reviews were evaluated. Results In all cases, an operative report was completed by a senior surgeon. Weight-bearing status was adequately documented in 91% of reports. Discharge summaries were completed for 82.5% of admissions, with 87.3% of these having instructions reflective of those in the operative report. Of first and second outpatient reviews, 69% and 73%, respectively, occurred within 1 week of the requested time. Previously documented management plans were changed in 30% of reviews. At 6-months post-operatively, 42% of patients had been reviewed by a member of their operating team. Discussion Orthopaedic medical record documentation remains an area for improvement. In addition, hospital out-patient systems perform suboptimally and may affect patient outcomes. What is known about the topic? Medical records are an essential tool in modern medical practice. Despite the importance of comprehensive documentation in the medical record, numerous examples of poor documentation have been demonstrated, including substandard documentation during consultant ward rounds by junior doctors leading to a breakdown in healthcare professional communication and potential patient mismanagement. Further inadequacies of medical record documentation have been demonstrated in surgical discharge notes, with complete and correct documentation reported to be as low as 65%. What does this paper add? Standards of patient care should be constantly monitored and deficiencies identified in order to implement a remedy and close the quality loop. The present study has highlighted that the standard of orthopaedic trauma medical record keeping at an Australian Level 1 trauma centre is below what is expected and several key areas of documentation require improvement. This paper further evaluates the system performance of the out-patient system, an area where, to the authors knowledge, there is no previous work published. The findings show that the performance was below what is expected for surgical review, with many patients failing to be reviewed by their operating surgeon. What are the implications for practitioners? The present study shows that there is a poor level of documentation and a standard of out-patient review below what is expected. The implications of these findings will be to highlight current deficiencies to practitioners and promote change in current practice to improve the quality of medical record documentation among medical staff. Further, the findings of poor system performance will promote change in the current system of delivering out-patient care to patients.

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