Developing the electronic patient medical record


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Developing the electronic patient medical record

  1. 1. Developing the ElectronicPatient Medical Records System (What Hospital Administrators Should Know) - Noel D. Lawas MD -
  2. 2. Session ObjectivesAt the end of the session, the participantsshould be able to:• Appreciate the breadth of possibilities in customizing what the system can do in support of managing information• Appreciate the true value of having a fully functional electronic patient medical records system• Describe tools which can be used to retrieve patient information and perform analysis
  3. 3. How Patient Health Records Are Linked to Majors Transactions of a Hospital
  4. 4. Simple (Manual) Records Management System Record Form Reports Filing Cabinet• Data written into a record form• Completed records are filed• Summary reports produced and printed
  5. 5. Activities Associated with the Handling of Patients Medical Records Patient Management Medical Records Mgt• Recordings of Requirements, • Patient Registration Observations and Services • Daily Patient Census Given to a patient • Registries – Patient Consent – Birth – Face Sheet – Death – Admission Record – Admission – Clinical History and PE – Discharge Findings – Laboratory Exam Results • Index – X-ray Results – Inpatient – OR and Anesthesia – Operation – TPR – Disease – Doctors’ Orders – Physician – Nurses’ Notes • Hospital Statistics • Quality Patient Records Mgt
  6. 6. Enhancing Simple Records ManagementSystem Through Automation IT Techniques Data Capture Database Mgt Report System Generation
  7. 7. Objectives of Automating Medical Records Management System• Achieve the highest possible efficiency, given the limitation of resources, in managing patient records – Faster service time – Complete and error-free records – Always available on demand – Increase productivity of hospital staffs – Increase “profit” margin
  8. 8. Limitations of Automating Medical Records Management System• Cannot take the place of important legal requirements attached to medical records• Not ideal for qualitative recordings• Details of many services/transactions are voluminous and very seldom used for management decision-making• Doctors and nurses have peculiar ways of describing different types of medical information
  9. 9. Common Techniques in Automating Data Capture• Limiting selection of possible entries in a data field (use of droplist, look-up table, etc.)• After selecting an entry, related fields are automatically filled up• Computation is performed after entering the needed set of data• Use of external devices like bar code reader.
  10. 10. Notes in Automating Report Generation• Used in generating regularly needed reports by management• Commonly used forms: – Printed reports – Web reports• Features – Limited to reports requiring straightforward calculations and data processing – Requires pre-determined specification of output information
  11. 11. Supercharging Records Management System Through a Computer Network System Data Capture Data Capture Database Mgt Report System Generation Data Capture Computer Network Environment
  12. 12. Advantages of Records Management Under a Networked Environment• Integrated system of records management – physical barriers disappear• All records within the system can be linked together. As such, linked records are treated as one (Eg. Useful in pts’ billing)• Complex reports needing inputs to different sets of records are easily generated.• All records are readily available to management anytime and anywhere
  13. 13. Example of Integration of Records Management Charge Slip Charge Slip (Nursing Srv) (Pharmacy) Network Server Charge Slip Charge Slip (Laboratory) (Other Fees) Charge Slip (Radiology)
  14. 14. Example of Using Linked Records to Achieve Greater Performance Registration Admission Diagnostic Exam Records Records Records Name Attending MD Date of Exam HIN Clin Service Name of Exam Address Bed No. Type of Exam PhilHealth Initial Dx Exam Fee Registration Record ~ Admission Record ~ Diagnostic Exam Performed Name HIN Attending MD Clin Service Date of Exam Name of Exam Type of Exam Exam Fee
  15. 15. Example of Complex Reports Needing Multiple Inputs Patient Billing Statement Itemized patient’s chargesAccommodation Professional Charge Slips Charges Fees
  16. 16. Example of Secured High Availability of Patients Medical Records (Using the world wide web)