Perception of electronic medical records (EMRs) by nursing staff in a teaching hospital in India

Background: Electronic Medical Records system (EMRs) in any healthcare system has the potential to transform healthcare in terms of saving costs, reducing medical errors, improving service quality, increasing patients’ safety, decision-making, saving time, data confidentiality, and sharing medical. Evidence on the current state of EMR system in Nigeria health system particularly its knowledge among health professionals is limited. Hence, this study was conducted to assess the level of knowledge EMRs among frontline health care workers in a tertiary health institution in Jos, Plateau State.Methods: This was a cross-sectional study conducted between April and August 2019 among 228 frontline health care workers in Jos University Teaching Hospital using quantitative method of data collection. SPSS version 20 was used for data analysis and a p-value of ≤ 0.05 considered statistically significant.Results: The mean age of the respondents in this study was 35 ± 8 years with 93 (40.8%) being 36 years and above. The overall level of knowledge of EMRs was adjudged to be good among 163 (71.5%) of the participants. Category (pharmacists) of the respondents was found to influence good knowledge of EMRs (OR = 1.37; 95% CI = 1.007 – 1.865; p = 0.045).Conclusions: This study has demonstrated a relatively high level of good knowledge of EMRs with variation existing along the categories of health care workers bringing to light the existence of a good knowledge base in the light of future EMRs implementation.

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Perfil epidemiológico e análise clínica de pacientes com pneumonia associada à ventilação mecânica em um hospital de ensino / Epidemiological profile and clinical analysis of patients with ventilation associated pneumonia in a teaching hospital

REVISTA CIÊNCIAS EM SAÚDE ◽

10.21876/rcsfmit.v8i3.766 ◽

2018 ◽

Vol 8 (3) ◽

pp. 14-18

Author(s):

Romenia Fernanda Leite ◽

Bruno Michel e Silva

Keyword(s):

Acinetobacter Baumannii ◽

Electronic Medical Records ◽

Teaching Hospital ◽

Medical Records ◽

Clinical Analysis ◽

Hospital Infection ◽

Microbiological Diagnosis ◽

Hospital Infection Control ◽

Hospitalization Period ◽

Epidemiological Profile

Introdução: A pneumonia associada à ventilação mecânica (PAV) é definida como aquela que se desenvolve 48h após o início da ventilação mecânica. O mecanismo comumente envolvido é a aspiração para as vias aéreas inferiores de secreções colonizadas. O diagnóstico de PAV pode ser clínico ou microbiológico. A PAV prolonga o tempo de internação e aumenta custos. Seu tratamento precoce e adequado está associado à redução da mortalidade. Objetivos: Traçar o perfil epidemiológico e realizar a análise clínica de pacientes diagnosticados com PAV, comparando o grupo de pacientes com diagnóstico clínico e os com diagnóstico microbiológico. Métodos: Foram avaliados 62 prontuários eletrônicos de pacientes diagnosticados com PAV no período de janeiro de 2015 a janeiro de 2017 no Hospital Escola de Itajubá (MG), de acordo com o banco de dados da Comissão de Controle de Infecção Hospitalar. Os dados coletados incluíram: idade; sexo; presença de febre; resultado da cultura; desfecho; causa do óbito; uso de antibiótico; tempo de internação; valores de leucócitos e proteína C-reativa (PCR). Resultados: Foram analisados 49 pacientes através de prontuários eletrônicos, com idade média de 60,5 anos, sendo 71,4% do sexo masculino. Quase 70,0% do total de casos de PAV teve diagnóstico microbiológico definido. O agente mais envolvido foi o Acinetobacter baumannii. A mortalidade foi de 55,0%. PCR estava elevada em quase 100,0% dos casos; febre esteve presente em 45,0% dos casos e leucocitose, em 70,0%. Conclusão: A PAV é frequente em unidades de terapia intensiva. Os agentes mais prevalentes são os gram-negativos e multirresistentes.Palavras-Chave: Pneumonia associada à ventilação mecânica; Infecção hospitalar; Intubação intratraquealABSTRACTIntroduction: Ventilation associated pneumonia (VAP) is defined as one which takes place 48 hours after the onset of mechanical ventilation. The mechanism commonly involved in the etiology is the aspiration of contaminated secretions into the lower airways. VAP diagnosis may be clinical or microbiological. VAP extends the hospitalization period and therefore its cost; early and appropriate treatment of VAP is associated with an expressive decrease of mortality. Aims: To identify the epidemiological profile, to perform clinical analysis of VAP diagnosed by comparing the group of patients with clinical diagnosis and those with a microbiological diagnosis. Methods: Sixty-two electronic medical records of patients diagnosed with VAP were evaluated from January 2015 to January 2017 at a Teaching Hospital, according to the Hospital Infection Control Committee database. Data collected included: age; sex; presence of fever; culture result; outcome; cause of death; use of antibiotic; leukocyte values and C-reactive protein (CRP). Results: Forty-nine patients were analyzed using electronic medical records, with a mean age of 60.5 years, of which 71.4% were male. Almost 70.0% of the total VAP had a definite microbiological diagnosis. The most involved agent was Acinetobacter Baumannii. Mortality was 55.0%. CRP was elevated in almost 100.0% of cases; fever was present in 45.0% of cases and leukocytosis in 70.0%. Conclusion: VAP is frequent in intensive care units. The most prevalent are the gram-negative and the multiresistant agents.Keywords: Ventilation associated pneumonia; Hospital infection; Endotracheal intubation

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Improving Communication Between Nursing Staff and Surgery Residents in the age of Electronic Medical Records

The American Surgeon ◽

10.1177/0003134820956290 ◽

2020 ◽

pp. 000313482095629

Author(s):

Jacob Veith ◽

Katherine Spitz ◽

Kevin Luftman ◽

Samuel Long ◽

Joselyn Martin ◽

...

Keyword(s):

Electronic Medical Records ◽

Nursing Staff ◽

Medical Records

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P17: IMPROVING PLASTIC SURGERY OPERATION NOTE ACCESSABILITY AT A MAJOR TRAUMA CENTRE: A PROSPECTIVE COMPLETED AUDIT CYCLE

British Journal of Surgery ◽

10.1093/bjs/znab117.102 ◽

2021 ◽

Vol 108 (Supplement_1) ◽

Author(s):

L Geoghegan ◽

D Reissis

Keyword(s):

Electronic Medical Records ◽

Nursing Staff ◽

Medical Records ◽

Reconstructive Surgical Procedures ◽

Trauma Centre ◽

Post Intervention ◽

Reminder System ◽

Major Trauma Centre ◽

Operation Note ◽

Limit Access

Abstract Introduction Quality operation note documentation is essential for ensuring continuity of care amongst the multi-disciplinary team. The Royal College of Surgeons has published clear and succinct guidelines which outline the necessity for timely, accurate and accessible operation note documentation. Our department uses a bespoke electronic operation note template which is stored within a departmental database. The aim of this study was to evaluate the effect of online operation note guidance on the accessibility of operative documentation. Method A prospective audit of operation note documentation was conducted during two one-month periods in May and November 2018. All reconstructive surgical procedures, both trauma and elective, were included. A bespoke online reminder system was introduced to our electronic platform to encourage operation note upload onto electronic medical records. Result 224 cases (127 elective, 98 consultant-led) were included in the initial audit and 239 cases (173 elective, 131 consultant-led) in the post-intervention audit. 56% of operation notes were accessible to nursing staff pre-intervention. Post-intervention 83% of operation notes were accessible to nursing staff (p< 0.05). No significant correlation was found between operation note accessibility and the type of case (elective vs emergency, r= -0.179), grade of operating surgeon (consultant vs registrar, r=0.259) and the number of operating surgeons (r=0.208). Conclusion This study highlights the importance of operation note accessibility to every member of the multidisciplinary team. A pop-up based intervention significantly improved accessibility of operation notes within electronic medical records although performance remains significantly below the expected standard. Take-home message The use of bespoke, online platforms may limit access to operation notes. A simple, pop-up based intervention significantly improves upload rate to electronic medical records however accessibility remains significantly below the expected standard.

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Doctors’ Attitude and Willingness to Use Electronic Medical Records at the Lagos University Teaching Hospital, Lagos, Nigeria.

Online Journal of Public Health Informatics ◽

10.5210/ojphi.v10i2.8416 ◽

2018 ◽

Vol 10 (2) ◽

Cited By ~ 1

Author(s):

Olanrewaju Olusola Onigbogi ◽

A O Poluyi ◽

C O Poluyi ◽

M O Onigbogi

Keyword(s):

Electronic Medical Records ◽

Teaching Hospital ◽

Medical Records ◽

Medical Training ◽

University Teaching ◽

Medical Doctors ◽

Skills Acquisition ◽

Work Duration ◽

Willingness To Use ◽

It Skills

ABSTRACTBackground: There have been few studies conducted on Electronic Medical Records (EMR) among medical doctors who practice in resource limited settings. This study aimed to assess the attitude to and willingness of medical doctors at the Lagos University Teaching Hospital to use EMR and to identify the factors that are associated with the willingness to use EMR.Methods: A stratified sampling method was used to select medical doctors to participate in the study according to their experience and professional cadre. A pretested self-administered questionnaire was used to collect data which were entered and analyzed using the Epi-info version 7 software. Statistically significant associations were tested using the chi-square and fishers exact tests.Results: There were 202 participants in the study. All (100%) had good attitude towards EMR. Nearly all of them (96.54%) were willing to use EMR. There was no significant association between age, gender and willingness to use EMR. However, there was a statistically significant association with work duration and IT skills (p< 0.05).Conclusion: Work duration and IT skills are significant factors in determining the willingness to use EMR. There is therefore a need to include IT skills acquisition in medical training so as to increase the chance of use of EMR.

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