Patient Medical Record
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Matthew Kahn ◽  
Antony D Grayson ◽  
Parminder S Chaggar ◽  
Marie J Ng Kam Chuen ◽  
Alison Scott ◽  

Abstract Aims We explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service. Methods and results PCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients’ records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record. Conclusion A PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.

Rajesh Hadia ◽  
Idrisi Mohammed Tousif ◽  
Avani Kapadia ◽  
Suchitra Pillai ◽  
Hemraj Singh Rajput ◽  

Background: Acne vulgaris remains one of the commonest diseases to afflict humanity, with over 90% of males and 80% of females affected by the age of 21 years. Objectives: The aim of this study was to assessing the specific risk factors, determine the epidemiology and etiology of Acne Vulgaris. Methodology: It is a cross-sectional observational study conducted for a period of six month in the department of dermatology, Dhiraj General Hospital, Vadodara. Patients who were diagnosed with acne vulgaris and fulfilled the inclusion criteria were enrolled in the study. Data was collected by filling the patient medical record sheet. Result: Total 300 patients were included in the study. Out of which 38.67% males and 61.33% females were found affected by Acne Vulgaris. The mean age group affected were found to be 21.77±4.06 years. When compared their social habits, patients consumed more caffeine (49.67%) than alcohol (24.67%), smoking (15.33%) and tobacco (5.67%). 32.33% patients also had history of seborrheic dermatitis. Using GAGS scale, we found 94% patients suffered from moderate Acne condition while 6% suffered from severe Acne condition. Conclusion: Acne Vulgaris was predominantly found in females in adolescence and in males in adulthood. The severity was found more in males than females. The common site for Acne Vulgaris was found to be face while comedones and papules were the common types of lesions. Stress was found to be one of the major aggravating factors for severity of Acne Vulgaris.

Rajesh Hadia ◽  
Juliet Joy Joseph ◽  
Jilce Mathew ◽  
Shivani Patel ◽  
Trupal Rathod ◽  

Background: World Health Organization Surgical Safety Checklist demonstrated a significant reduction in both morbidity and mortality. Objectives: This study aimed to find out the feasibility of implementation of WHO Surgical safety checklist in the routine practice, to ensure the teams follow critical safety steps, consistency in patient safety, and to maintain a culture that values achieving it, to assess the pre-operative status and post-operative quality of recovery among the patients undergoing surgery. Methodology: It is a prospective and observational study. A total of 65 patients of age group 18 and above were included in the study. The data was collected by filling the patient medical record sheet. Result: A total of 65 patients were included in the study. 64.62% were male, 35.38% were female. Out of 65 patients 61.54% experienced pre-operative anxiety; of which 20% of patients (n=9) showed very fast to fast recovery, 27.5% of patients (n=11) showed moderate recovery) and 52.5% of patients (n=21) showed slow to very slow recovery. Conclusion: Implementation of the WHO surgical safety checklist may improve miscommunications between the OR team, avoid unexpected errors ((Improving teamwork and communication). Appointing a staff or member of the OR team with the responsibility to check the checklist may improve the feasibility to implement the WHO SSC. The level of pre-operative anxiety greatly influences postoperative recovery. Thus, the Surgical and Anaesthetic team must assess the patient's pre-operative anxiety and take the necessary step before surgery.

2021 ◽  
Vol 3 (2) ◽  
pp. 47-54
Wiji Novarianti ◽  
Muhammad Syukri ◽  
M. Dody Izhar ◽  
M Ridwan ◽  
Faisal Faisal

Introduction: Pneumonia accounts for 16 % of the causes of death in children under five including in Indonesia. This study aims to determine nutritional status, provide vitamin A capsules, and complete immunization as risk factors for pneumonia in toddlers aged 18-59 months. Methods: This study used a case-control design with 47 cases and 47 control children. The case was a toddler with pneumonia aged 18-59 months who was registered at Puskesmas Paal V Jambi City. Controls were toddlers who did not experience pneumonia with age (range ≤3 months), gender, and came from the same sub-district as the case toddler. Sampling was done by purposive technique by selecting the latest patient medical record data. Data collection was carried out by interview method in October-November 2020. Data analysis was carried out univariate and bivariate using the Chi-Square test. Results: The results showed nutritional status (p=0.023 OR=3.93 95% CI 1.29-11.96), Vitamin A capsules administration (p=0.026 OR=3.12 95% CI 1.23-7.91) is a risk factor for pneumonia in children under-five. Complete immunization is nor a risk factor for pneumonia in children under five. Conclusion: The conclusion of the study was nutritional status and vitamin A administration as risk factors for pneumonia in children aged 18-59 months.

2021 ◽  
Vol 4 (1) ◽  
pp. 63-73
Dewi Puspita Apsari ◽  
Ni Made Krisna Dwiyanti ◽  
I.B.N. Maharjana I.B.N. Maharjana ◽  

Hospitalized community-acquired pneumonia (CAP) patients are always prescribed intravenous (IV) antibiotics. Inappropriate and unnecessary IV antibiotics usage leads to an increase in healthcare costs and bacterial resistance. IV to per oral (PO) conversion therapy can overcome these problems. The aim of the study was to evaluate the practice of switching from intravenous to oral antibiotics of inpatients with community-acquired pneumonia (CAP). This retrospective observational study was conducted by taking patient medical record from january until december 2019. Outcomes of the study are patient characteristics, pattern use, antibiotic and type conversion therapy. Adult inpatients on conversion therapy were eligible for study enrollment. Data were analyzed descriptively using SPSS 17.0. The study showed that among 78 patients who were eligible for conversion therapy. Most of the patient has mean duration conversion therapy 48-72 hours as much as 55 (70,5%). Beta-lactams were the most commonly converted antibiotics. However, the step-down therapy was the major type of conversion practiced in this study as much as 48 (61,5) followed by sequential and switch over with numbers 21 (27%) and 9 (11,5%) respectively. Based on the study findings wangaya hospital should improve the practice of sequential therapy in order to reduce the burden of CAP.

2021 ◽  
Vol 12 (03) ◽  
pp. 479-483
Holly B. Ende ◽  
Michael G. Richardson ◽  
Brandon M. Lopez ◽  
Jonathan P. Wanderer

Abstract Background The Accreditation Council for Graduate Medical Education establishes minimum case requirements for trainees. In the subspecialty of obstetric anesthesiology, requirements for fellow participation in nonobstetric antenatal procedures pose a particular challenge due to the physical location remote from labor and delivery and frequent last-minute scheduling. Objectives In response to this challenge, we implemented an informatics-based notification system, with the aim of increasing fellow participation in nonobstetric antenatal surgeries. Methods In December 2014 an automated email notification system to inform obstetric anesthesiology fellows of scheduled nonobstetric surgeries in pregnant patients was initiated. Cases were identified via daily automated query of the preoperative evaluation database looking for structured documentation of current pregnancy. Information on flagged cases including patient medical record number, operating room location, and date and time of procedure were communicated to fellows via automated email daily. Median fellow participation in nonobstetric antenatal procedures per quarter before and after implementation were compared using an exact Wilcoxon-Mann-Whitney test due to low baseline absolute counts. The fraction of antenatal cases representing nonobstetric procedures completed by fellows before and after implementation was compared using a Fisher's exact test. Results The number of nonobstetric antenatal cases logged by fellows per quarter increased significantly following implementation, from median 0[0,1] to 3[1,6] cases/quarter (p = 0.007). Additionally, nonobstetric antenatal cases completed by fellows as a percentage of total antenatal cases completed increased from 14% in preimplementation years to 52% in postimplementation years (p < 0.001). Conclusion Through an automated email system to identify nonobstetric antenatal procedures in pregnant patients, we were able to increase the number of these cases completed by fellows during 3 years following implementation.

Theodore Poufos ◽  
Georgios Rigakos ◽  
Stefanos Labropoulos ◽  
Kalliopi Stathaki ◽  
Ioanna Theodorakopoulou ◽  

ABSTRACT Introduction Quality in healthcare delivery is important for the safety and experience of patients with cancer. Effective documentation is an integral component of quality improvment, and accurate documentation can be affected by prompts in the medical record, potentially improving quality of services. Methods The Contemporary Oncology Team (COT) is a Greek private oncology practice that participated in the American Society of Clinical Oncology's (ASCO's) Quality in Oncology Practice Initiative (QOPI). Between 2014 and 2019, COT implemented changes in its paper patient medical record, in order to improve quality of care and documentation. Fields regarding pain, emotional well-being and psychosocial assessment, discussions with the patient and consent about treatment and disease, medication details and cumulative dose, treatment goals, side-effect grading, pregnancy screening, treatment adherence and anticipated duration were added. In this report, we present the association of these improvements with COT performance in QOPI. Results Pain and emotional well-being assessment and documentation were significantly improved by the development of a structured patient follow-up form. In contrast, the assessment of fertility issues, tobacco use, and the documentation of treatment plan and intent did not present a drastic change, because COT performance was already above QOPI average. Conclusion A thorough reform of COT paper medical record according to QOPI standards improved QOPI scores, but more importantly effected a shift in the team's culture to safer and more standardized quality based care.

2021 ◽  
Vol 6 (1) ◽  
pp. 139
Sudjiran Sudjiran ◽  
Akbar Syahbanta Limbong

Along with the development of technology, the speed of data processing is needed in order to compete with competitors. A company must have an advantage over other companies if it does not want to lose in the competition. MRCCC Siloam Semanggi is a company that provides health services for cancer patients. One of the transaction processes within the hospital is sensing data in the form of images of patient data. Image data processing activities at this hospital are not yet structured and require a database in order to assist in fast data processing. This study aims to create an image transfer system to transfer physical documents into digital documents. This system is useful for hospital employees to be able to find documents easily for certain purposes, the system is made web-based using XAMPP, using PHP language with MySQL database. The results of the analysis of research that has been done, there are problems that arise related to the retention system in hospital patient data. Retention data collection activities are usually carried out by sorting out patient medical record documents from those not recorded on a computer.

2020 ◽  
Vol 6 (2) ◽  
pp. 35-43
Lilin Turlina ◽  
Faizatul Ummah ◽  

The incidence of premature rupture of membranes (PRM) ranges from 8-10% at term pregnancy and 1% in preterm pregnancy. The incidence of PRM at RSUD dr. SoegiriLamongan in 2017 amounted to 16,43%. The purpose of this study was to analyze risk factors of the occurrence of premature rupture membranes in RSUD Dr. SoegiriLamongan. The research used descriptive analytical method with cross sectional approach. The sample is 268 maternity mothers, divided into 134 mothers giving birth with PRM  and 134 normal maternity mothers at Dr. Soegiri Lamongan on 2018. Sampling is done by simple random sampling. Data collection uses patient medical record and with multivariate multiple logistic regression analysis.The results showed that presentation abnormalities with a p value of 0.045 <0.05 and CPD with a p value of 0.002 <0.05. Based on the Odds Ratio (OR) values ​​as follows: Maternal age OR 1,141, OR parity 0.933, OR fetal presentation 2,779, OR Twins 1,394, OR CPD 6. and OR Large infants 0.783.Meaning that there was a significant influence between fetal presentation and CPD on PRM.

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