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From Raw Data to Insights
Published in Disa Lee Choun, Anca Petre, Digital Health and Patient Data, 2023
Medical records are considered one of the cornerstones of healthcare. They contain all relevant information about a patient: medical history, diagnosis, treatments, allergies, labs tests, imagery, etc. They allow health professionals to treat patients to the best of their abilities, provided that the information contained in EHRs is complete and reliable. In comparison to previous handwritten notes, EHRs represent a significant step forward. They facilitate data accessibility and sharing, decrease the risk for transcription errors and reduce costs associated with repeated medical tests. For physicians, they represent an optimized workflow and time savings.4
China's Mental Health Law Reform
Published in Bo Chen, Mental Health Law in China, 2023
In addition, the right of guardians may still prevail in certain situations. For example, the MHL requires that a mental health facility must allow service users and their guardians to access and copy their medical record.87However, unlike the rule of accessing medical records in general health care, the right of a service user could be legally restricted, if accessing or copying medical record would be potentially detrimental to their treatment.88The MHL does not clarify this standard, but it is very likely to be determined by psychiatrist.89By contrast, the guardian’s right to access the medical records must be ensured, regardless of any situation.90
The Role of the Medical Examiner
Published in Jason Payne-James, Suzy Lishman, The Medical Examiner Service, 2023
The medical record may take the form of a physical set of notes, an electronic patient record or a combination of the two. These may be brief (for example, a death taking place in an emergency department) or voluminous (for example, a death of an elderly patient with multiple comorbidities and a prolonged in-hospital stay). Irrespective of where the death has occurred or the type of patient record available, the attention to detail and quality of scrutiny should be of the same high standard.
Validity of clinical psoriatic arthritis diagnoses made by rheumatologists in the Swedish National Patient Register
Published in Scandinavian Journal of Rheumatology, 2023
JK Wallman, G-M Alenius, E Klingberg, V Sigurdardottir, S Wedrén, S Exarchou, U Lindström, D Di Giuseppe, J Askling, LTH Jacobsson
All individuals, alive and residing in Sweden on 31 December 2015, and having received at least one ICD code for PsA (ICD-8: 696.00; ICD-9: 696A; ICD-10: L40.5, M07.0, M07.1, M07.2, or M07.3) as main or secondary diagnosis in 1968–2015, were identified from the NPR. For the current validation, a subpopulation of all such prevalent PsA patients in 2015 was selected, by defining inclusion criteria requiring at least one ICD-10 code for PsA as the main diagnosis from an outpatient visit (i.e. in the OPR) to a rheumatology or internal medicine department in 2013–2015. The rationale for the 2013–2015 time period was to ensure that the medical records would be accessible, sometimes spanning several decades, but at the same time to allow some years to have passed before the medical record review was performed in 2019 (see ‘Validation process and outcomes’, below), to enable some accumulation of clinical information also for incident cases. Furthermore, PsA patients in Sweden are typically diagnosed and treated in specialized outpatient care (18), normally at departments of rheumatology or internal medicine (in non-university hospitals, rheumatology is often part of internal medicine), although milder cases, not requiring disease-modifying anti-rheumatic drug therapy, may be referred back to primary care after the diagnosis has been made.
Modelling the factors affecting Nigerian medical tourism sector using an interpretive structural modelling approach
Published in International Journal of Healthcare Management, 2021
Erhauyi Meshach Aiwerioghene, Mahavir Singh, Puneeta Ajmera
The medical record is a vital part of any hospital and healthcare sector; there is a need to improve the medical document in Nigeria. This will, in turn, help future research work and post care follow-up and future consultation. The need to introduce an electronic medical record system in all healthcare settings is to improve the quality of medical records. Downloading data from electronic medical records is faster and easier, mostly in emergencies and cases of tracking and research, etc. An electronic medical record system will be a very good replacement for ‘paper-based’ medical record systems. Nevertheless, there must be an administrative mechanism, for instance, inspection for physicians and nurses who are about to neglect this system, to develop and implement these phases and to continuously train the healthcare staff. Hardware and specific software features should be available to avoid the effect of the change from a ‘paper-based system’ to a new electronic system [27].
The behavior of specialist towards completeness of medical records
Published in International Journal of Healthcare Management, 2021
Ernawaty Ernawaty, Thinni Nurul Rochmah, Widodo J. Pudjirahardjo, Mohammad Junaidi
These following recommendations are offered as the implications of the results of this research: (1) Completeness of medical record filling should be used as an indicator of performance in hospital. Director’s regulations, good socialization, and regulation enforcement are necessary to be implemented. (2) Analysis of workload on each specialist must be conducted to reveal the real workload. (3) Functional Medical Staff (FMS) groups and Medical Committee as representatives of specialists must be involved in arranging improvement and periodic evaluation of medical record files. (4) Sustainable evaluation and socialization on the contents of Mutual Handbook for Medical Record Filling must be performed as a reference for filling medical records. (5) The Mutual Handbook for Medical Record filling must be copied for all specialists, and put in all rooms. (6) The hospital should immediately create an EMR system to enhance the supervision of completion and punctuality of medical record filling. Electronic medical records can be considered as an advancement in consumer health informatics. E-medical records have been adopted in many nations, whereas other countries are planning to adopt this technology.