Nursing & Health Record Keeping Survival Guide Merrix Pauline and Lillyman Sue Nursing & Health Record Keeping Survival Guide42pp £5.99 Pearson 9780273760641 0273760645

2014 ◽  
Vol 20 (10) ◽  
pp. 16-16
Author(s):  
Grant Byrne
Keyword(s):  
Health Record ◽  
Record Keeping ◽  
Nursing Health

scholarly journals Tensions in Representing Behavioral Data in an Electronic Health Record

2021 ◽  
Author(s):  
Gabriela Marcu ◽  
Anind K. Dey ◽  
Sara Kiesler
Keyword(s):  
Electronic Health Record ◽  
Behavioral Health Care ◽  
Behavioral Data ◽  
Research Approach ◽  
Prototype System ◽  
Health Record ◽  
Record Keeping ◽  
Action Research Approach ◽  
Electronic Health ◽  
The Moment

AbstractTaking an action research approach, we engaged in fieldwork with school-based behavioral health care teams to: observe record keeping practices, design and deploy a prototype system addressing key challenges, and reflect on its use. We describe the challenges of capturing behavioral data using both paper and electronic records. Creating records of behaviors requires direct observation, and as a result the record keeping responsibility is challenging to distribute across a care team. Behavioral data on paper must be transferred and prepared for reporting, both inside the organization and to stakeholders outside of the organization. In prototyping a computerized working record, we targeted user needs for capturing details of a behavioral incident in the moment. Challenges persisted through the transition from paper to our prototype, and based on these empirical findings over two years of fieldwork, we present five tensions in representing behavioral data in an electronic health record. These tensions reflect the differences between entering behavioral data into the record for intraorganizational use versus interorganizational use.

SCHOOL HEALTH RECORD KEEPING

1963 ◽  
Vol 33 (3) ◽  
pp. 125-127 ◽  
Author(s):  
ANN T. GARBER
Keyword(s):  
School Health ◽  
Health Record ◽  
Record Keeping

Adopting nursing health record standards

2013 ◽  
Vol 39 (1) ◽  
pp. 1-14 ◽  
Author(s):  
Álvaro Rocha ◽  
Bruno Rocha
Keyword(s):  
Health Record ◽  
Nursing Health

scholarly journals Audit and feedback intervention: An examination of differences in chiropractic record-keeping compliance

2014 ◽  
Vol 28 (2) ◽  
pp. 123-129 ◽  
Author(s):  
Nicole M. Homb ◽  
Shayan Sheybani ◽  
Dustin Derby ◽  
Kurt Wood
Keyword(s):  
Treatment Plan ◽  
Practical Importance ◽  
Audit And Feedback ◽  
Health Record ◽  
Feedback Report ◽  
Improvement Program ◽  
Feedback Intervention ◽  
Record Keeping ◽  
Documentation Quality ◽  
Quality Health

Objective The objective of this study was to investigate the association of a clinical documentation quality improvement program using audit–feedback with clinical compliance to indicators of quality chart documentation. Methods This was an analysis of differences between adherence to quality indicators of chiropractic record documentation and audit–feedback intervention (feedback report only vs. feedback report with one-on-one educational consultation) at different campuses. Comparisons among groups were analyzed using analysis of variance (ANOVA), Tukey or Dunnett post hoc tests, and Cohen's d effect size estimates. Results There was a significant increase in the mean percentile compliance in 2 of 5 compliance areas and 1 of 11 compliance objectives. Campus B demonstrated significantly higher levels of compliance relative to campus A and/or campus C in 5 of 5 compliance areas and 7 of 11 compliance objectives. Across-campus comparisons indicated that the compliance area Review (Non-Medicare) Treatment Plan [F(2,18) = 17.537, p < .001] and compliance objective Treatment Plan Goals [F(2,26) = 5.653, p < .001] exhibited the highest practical importance for clinical compliance practice. Conclusions Feedback of performance improved compliance to indicators of quality health record documentation, especially when baseline adherence is relatively low. Required educational consultations with clinicians combined with audit–feedback were no more effective at increasing compliance to indicators of quality health record documentation than audit–feedback alone.

scholarly journals The experience of home nurses with an electronic nursing health record

2010 ◽  
Vol 57 (4) ◽  
pp. 508-513 ◽  
Author(s):  
K. De Vliegher ◽  
L. Paquay ◽  
S. Vernieuwe ◽  
H. Van Gansbeke
Keyword(s):  
Health Record ◽  
Nursing Health

Quality evaluation of oral health record-keeping for Finnish young adults

1998 ◽  
Vol 56 (5) ◽  
pp. 288-292 ◽  
Author(s):  
Sari E. Helminen, Miira Vehkalahti,
Keyword(s):  
Young Adults ◽  
Oral Health ◽  
Quality Evaluation ◽  
Health Record ◽  
Record Keeping

scholarly journals Web-Based Interactive Health Record System (WIHRS)

2020 ◽  
Vol 5 (7) ◽  
pp. 790-794
Author(s):  
Folake Akinbohun ◽  
Ambrose Akinbohun ◽  
Omoniyi Akintunde Ojo ◽  
Babalola Daodu
Keyword(s):  
Care Delivery ◽  
Medical Personnel ◽  
Health Record ◽  
Service Model ◽  
Record System ◽  
Web Based ◽  
Record Keeping ◽  
Web Technologies ◽  
Interactive Health ◽  
Optimal Efficiency

A Web Based Interactive Health Record System (WIHRS) is a digital web-based record of patients presenting in a hospital. The information so generated on patients can then be accessed by medical personnel to provide treatment for them in any health care delivery setting at any location.  Analogue ways of record keeping were the traditional way of documenting patients’ information by health information officers. The problems of unavailability of a centralized database system and inability to access patients records and provide prompt treatment to patients at any healthcare centre could be solved by WIHRS. The objective of the paper is to design a WIHRS. The methods included cloud computing model, service model, deployment model and cloud hosting. The web technologies languages such as Hypertext Pre-processor (PHP), Hypertext Mark-up Language (HTML), Cascading Style Sheet (CSS) and Ajax were deployed to implement the proposed system. The use of WIHRS improves the standard of healthcare to patients with optimal efficiency.

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