The document discusses an electronic health record (EHR) system that aims to provide a comprehensive lifetime medical record for patients. It describes the key components of an EHR including demographics, medical history, examinations, investigations, diagnoses, treatments, and the ability to view trends over time. The EHR aims to store data in a structured way for analysis while maintaining usability.
Railhealth Electronic Medical Record encompasses the information and capabilities required to support healthcare service delivery. This presentation gives you the information regarding the features, objectives and the benefits what doctor gets by using our EMR.
An electronic health record (EHR) is a collection of patient’s electronically-stored health information in a digital and systematic format. EHR system can store data accurately.
Electronic Health Record System and Its Key Benefits to Healthcare IndustryCalance
This case study discusses how Electronic Health Record can turn out to be a solution to the problems associated with paper based clinical records. It’s a future-proof solution decreasing chances of error and loss while increasing patient-provider communication. Find out the key challenges faced by US health industry, key benefits of EHRs, and how Calance can help developing an HER solution. For more info about Calance, visit http://www.calanceus.com
In this presentation, you’ll learn all about electronic health records (EHRs), what types of data they can store, what their benefits are and why they are needed for achieving Meaningful Use.
Looking for more info? The last slide has a list of resources for you to continue learning about EHRs.
What is Health Informatics?
HI Goals
HI stakeholders
HI subfields / subspecialties
Healthcare trends & HI
HI professional environments
HI education / training opportunities & degrees
HI organizations / journals / meetings / events
HI professional certificates
HI books
Railhealth EMR encompasses the information and capabilities required to support healthcare service delivery, where the information is captured in a computer-readable form that supports interoperability and clinical decision support.
In this presentation, you will know regarding the features, objectives and benefits by using our Railhealth EMR
Railhealth Electronic Medical Record encompasses the information and capabilities required to support healthcare service delivery. This presentation gives you the information regarding the features, objectives and the benefits what doctor gets by using our EMR.
An electronic health record (EHR) is a collection of patient’s electronically-stored health information in a digital and systematic format. EHR system can store data accurately.
Electronic Health Record System and Its Key Benefits to Healthcare IndustryCalance
This case study discusses how Electronic Health Record can turn out to be a solution to the problems associated with paper based clinical records. It’s a future-proof solution decreasing chances of error and loss while increasing patient-provider communication. Find out the key challenges faced by US health industry, key benefits of EHRs, and how Calance can help developing an HER solution. For more info about Calance, visit http://www.calanceus.com
In this presentation, you’ll learn all about electronic health records (EHRs), what types of data they can store, what their benefits are and why they are needed for achieving Meaningful Use.
Looking for more info? The last slide has a list of resources for you to continue learning about EHRs.
What is Health Informatics?
HI Goals
HI stakeholders
HI subfields / subspecialties
Healthcare trends & HI
HI professional environments
HI education / training opportunities & degrees
HI organizations / journals / meetings / events
HI professional certificates
HI books
Railhealth EMR encompasses the information and capabilities required to support healthcare service delivery, where the information is captured in a computer-readable form that supports interoperability and clinical decision support.
In this presentation, you will know regarding the features, objectives and benefits by using our Railhealth EMR
This is about an Electronic Medical Record System for General Practitioners, especially for those who are from developing countries like Sri Lanka. Details are there in www.lakmedi.com
Information systems for health decision making - a citizen's perspectiveErdem Yazganoglu
We make health decisions everyday. We get our information from the Internet. As a society we are investing large amounts of funding for the health information systems. In this presentation, I tried to look from the perspective of a citizen and tried bringing a different perspective.
Horizon to Horizon--An Overview Electronic Health Record and Telehealthslvhit
Two Information tools, the electronic medical record and telehealth technology, have huge potential to improve quality and value of health care, especially in rural America. Dr. Ringel will discuss how we have barely scratched the surface of what can be accomplished with these powerful implements. His presentation will explore fundamental principles for using the EMR and telehealth most effectively.
Utility and Added Value of Classifications in Health Information SystemsBedirhan Ustun
Health Information Systems; ICD, ICD11, SNOMED-CT, Use Cases showing benefits of use of classification- terminology systems; avoid and e-tower of Babel; electronic health record, Enhance Patient Care, Decision Support, Safety & Quality
The impact of eHealth on Healthcare Professionals and Organisations: Health Information Management Systems in Modern Health Care. Shemer J. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)
Bahmni - An OpenMRS based Electronic Health Record System (Demo)Bahmni
This is a presentation created by Mr Ananth Raut from Possible Health, to demo features Bahmni.
For more details please visit:
http://possiblehealth.org/
http://bahmni.org/
Poster 1 presented at QCOR Baltimore 2014 MLoboLBNicolau
"QCOR 2014 presentation start today. 2 CUTEHeart posters to present: ""Comparison of the Healthcare Systems of the United States and Portugal: Epidemiology and Management of Coronary Heart Disease""
HTH 2304, Introduction to Health Information Management 1.docxaryan532920
HTH 2304, Introduction to Health Information Management 1
Course Learning Outcomes for Unit III
Upon completion of this unit, students should be able to:
1. Discuss the legal aspects of health information management.
1.1 Discuss legal issues that impact electronic health records.
7. Assess the impact of emerging health information technology applications on the healthcare industry.
7.1 Discuss the technology changes from paper documentation to electronic documentation.
Course/Unit
Learning Outcomes
Learning Activity
1.1
Chapter 5
Article: “Redefining the ‘Legal Medical Record’ and How to Be Prepared to
Respond to Legal Requests for a Patient’s Legal Medical Record”
Unit III Assessment
7.1
Unit Lesson
Chapter 5
Article: “We Want People to have Access to Their Medical Data on Their
Smartphones”
Unit III Assessment
Reading Assignment
Chapter 5: Electronic Health Records
Additional Reading Assignment:
In order to access the following resources, please click the links below.
Arndt, R. Z. (2017). We want people to have access to their medical data on their smartphones. Modern
Healthcare, 47(34), 30. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest-
com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1931806312/AB94CC8C67B04
D08PQ/1?accountid=33337
Finkelstein, M. M., Esq. (2017). Redefining the “legal medical record” and how to be prepared to respond to
legal requests for a patient’s legal medical record. The Journal of Medical Practice Management:
MPM, 33(1), 11–14. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest-
com.libraryresources.columbiasouthern.edu/docview/1933854979?accountid=33337
Unit Lesson
Electronic Health Records
Health information systems are filled with patient data. Without patient data, there would not be a need for
health information systems. These data can take many forms, from a medical diagnosis to a therapeutic
regimen or from a laboratory result to a personal food diary. Through electronic record keeping, healthcare
providers and organizations are able to collect, organize, and analyze patient data to support and improve
clinical decision-making and to deliver more timely and effective care. Patients, too, are enjoying greater
UNIT III STUDY GUIDE
Electronic Health Records
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest-com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1931806312/AB94CC8C67B04D08PQ/1?accountid=33337
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest-com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1931806312/AB94CC8C67B04D08PQ/1?accountid=33337
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest-com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1931806312/AB94CC8C67B04D08PQ/1?accountid ...
Christopher Tashjian - How technology is changing rural medicine: Fact, not t...Plain Talk 2015
Presented by Christopher Tashjian, MD, FAAFP, on September 27, 2013 at the fourth annual Center for Health Literacy Conference: Plain Talk in Complex Times.
During the workshop, the Trillium II project was presented to the audience as well as the state of patient summaries in Denmark and the US. Furthermore, the results of a survey on use of patient summaries in disaster and relief situations were presented.
The purpose of the workshop was to promote the project and the Global Community for Digital Health Innovation and collect feedback on the participants’ attitude towards patient summaries.
The workshop participants were invited to discuss which patient summary use cases they considered most relevant for the Trillium II project to focus on and how an international patient summary should be governed.
Secondary Data SourcesThe health record’s primary purpos.docxrtodd280
Secondary Data Sources
The health record’s primary purpose is patient care and reimbursement for encounters.
In order to see trends in a population of patients, you look at the data that is extracted from the records and enter it into databases – registries, indexes, etc.
These data sources are referred to as secondary data sources.
HIM Roles in Managing Secondary Records and DatabasesEstablishing database:
Determining content of database
Ensuring compliance with laws, regulations, and accreditation standards
Data dictionary
Data steward: oversees that data put in database or registery is accurate and complete
Differences Between Primary and Secondary Data Sources
Primary data source: medical record… b/c it contains information about a patient that has been documented by a healthcare professional
Secondary data source: data contained in indexes, registries and similar databases
Ways to classify data:
Patient-specific/identified data
Patient identified within the data. Every fact recorded in the record relates to a patient by name.
Patient identifiable data
If identify of patient can be derived or inferred from the data with or without the assistance of a computer. Can the patient be identified by date of birth, phone #, zip code,
Aggregate data
Data on groups of patients without identifying any particular patient individually
Purposes and Users of Secondary Data SourcesFour major purposes to collect secondary data:
Quality, performance, and patient safety
Research – data entered into databases help researchers determine treatment plans
Population health – require information be reported about certain diseases to prevent spreading
Administration – facilities are required to check physicians in the national database for information on previous malpractice or action against the physician
Internal Users
Users within the organization
Examples: Medical staff, Management staff
Identify patterns and trends that are helpful in patient long term care, benchmarking with other facilities.
External users
Individuals and institutions outside the facility
Examples: State data banks, Federal agencies
Federal government collects data from states on vital events like births and deaths
Types of Secondary Data Sources
Facility-specific indexes: enable health records to be located by diagnosis, procedure, physician. Originally kept on cards, now in computerized databases due to technology.
Broken down into several types… let’s discuss those types!
Master Population /Patient Index (MPI)
Disease and Operation Index
Physician Index
Registries
Purpose: to collect data from health records and to make them available for users
Registries contains more extensive information than indexes.
Index reports created using data from existing facility databases.
Registries contain more extensive data from the patient record.
Each registry must define the cases that will be included: case definition
Case finding used to identify the patients who have bee.
The annual physical exam allows physicians to detect changes that could affect their patients’ health, but there are debates as to whether it is really necessary.
Health Management System is created to give more knowledge and power to the doctors to record, update, and keep track of all reports of the patients. With its use, all medical data is saved electronically inclusive of patient vitals, vaccine records, demographic details, doctors notes of each visit, medical reports etc.
Doctors can schedule their appointments more accurately saving their time.
Health Management System (HMS) aims to create a system that allows, safely and securely, to keep all medical data online to be shared with and by all health professionals and researchers any time, any where in the world.
Chronic progressive external ophthalmoplegiaPS Deb
Chronic progressive external ophthalmoplegia (CPEO) is a descriptive term for a heterogeneous group of disorders characterized by chronic, progressive, bilateral, and usually symmetric ocular motility deficit and ptosis, without pain, proptosis and pupil involvement. Commonly a syndrome of Mitochondrial Cytopathy.
This is a short presentation at Down Town Hospital clinical meeting for DNB Medicine students. It dose not cover the all aspects of stroke care especially Thrombolysis, since it is difficult to practice for Medical specialist, and ischemic stroke is not common in North East India
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
4. Ideal Medical Record 18/06/10 Electronic Health Record Womb to tomb Health Record Acute EPR Social Care Direct Walk-In Centres Primary/Community EPR MMR Vaccination Meningitis Vaccination Alzheimer's Divorce Redundancy Depression Panic attacks Suspected cancer Fractured Femur Appendicitis Additional data associated with healthcare event, e.g. referral details, test results etc. Road Traffic Accident
5. Migrating from Paper to Electronic Data Starting Point “ the way I do it now” Paper “ feels like typing or dictating” Electronic free text “ feels like filling in a form” Partially structured “ feels like picking everything from a huge menu” Rigidly structured
6. Spectrum of National Health System 18/06/10 Community Visits Out Patients Visits GP/practice nurse Attends A&E Visits a walk-in centre Calls NHS Direct Uses NHS Direct.online Uses the Home Health Care Guide Calls OOH service Attends as in-patient Is visited at home by GP, nurse, care worker, midwife etc Goes to the pharmacy Visits the dentist
7. 18/06/10 EHR EHR Architecture INVESTIGATION REPORTS Blood test Biochemistry Imaging CLINICAL DATA Histories Examination DEMOGRAPHICS NHS Number Name, Address Date of Birth, Sex Registered GP/Contact details HA/EHR identifier Potential ‘Patient URL’ DIAGNOSIS AND TREATMENT DATA
8. Primary Objective of EHR 18/06/10 Patient Care Legal Management Research Education Audit Decision Support
12. 18/06/10 The Encounter detail shows the past visit date time and type of visit The screen holds information about the personal details of the patient like Patient NI No, Name, NSH No, Age Sex Place , Referral Doctors name and Diagnosis with treatment details It has search feature, using which the user can access the desired patient’s NI No, NHS No or First name
13. Appointments 18/06/10 The appointments section opens up the appointments for the current day, for all the doctors registered into the software. The user can book appointments for the patient, with any particular doctor from here. The weekly and monthly appointments can also be viewed.
14. 18/06/10 A new patient can be registered. His/her personal, home, job, and other details can be entered from here. The Encounter detail are entered here
16. 18/06/10 Temporal History Electronic Health Record History 2 History 5 History 3 History 4 History 1
17. 18/06/10 The history of the patient’s present illness are recorded & reflected here. History of present illness can be recorded
18. 18/06/10 There is a dropdown list of the Systems in the body. Selecting a particular System brings up another exhaustive list of Symptoms pertaining only to the System selected.
19. 18/06/10 Symptom details can be recorded in a more formal and structured way for analysis and Decision support
20. 18/06/10 History of the patient’s past illness and family history of illnesses can be recorded here, in order to trace any hereditary illness.
21. 18/06/10 Temporal Examination Electronic Health Record Examination 2 Examination 5 Examination 3 Examination 4 Examination 1
22. 18/06/10 Clinical Examination details can be recorded here. A long exhaustive list of examinations is provided. This would open up another screen, in which questions for the selected examination are asked and the answers are fed into the system. This information is used to generate a calculated report for the same.
23. 18/06/10 Pre-formatted medical examination can be changed with negative findings Body weight and vitals can be entered in structured text for follow up, analysis and trend
25. Temporal record of Investigation 18/06/10 Electronic Health Record Investigation 2 Investigation 5 Investigation 3 Investigation 4 Investigation 1
26.
27. 18/06/10 The relevant screen shows up when the lab test is selected from the list. Details pertaining strictly to the selected lab test are to be filled in by the user.
29. Temporal record of Life time Diseases 18/06/10 Electronic Health Record Disease 2 Disease 5 Disease 3 Disease 4 Disease 1
30. 18/06/10 The diagnosis of the patient with date and ICD code is recorded in this screen The Details of Diagnosis con be entered by double clicking on Diagnosis The Functional Status Score of the system can be calculated. Assessment of case is recorded for each visit.
31. 18/06/10 The Functional Status of the patient and different scales are used for follow-up Discussion of the case is entered in this screen with reason for diagnosis and plan for treatment t.
33. 18/06/10 List of drug used for patient are recorded chronologically. Details of prescription is recorded clicking the drug, where start date, end date, dosage, unit, route, frequency, and duration are recorded Effect and side effect of the drug is recorded chronologically
38. Statistics 18/06/10 Statistics of the Diagnosis, Symptom, and Lab Test are depicted as graphs which enables the doctor to analyze his/her practice.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49. Paper Partially structured Rigidly structured Achieving an Optimum Balance is Key Electronic free text Starting Point Usefulness of Data Impact on Usability Optimum Value
Editor's Notes
What is a medical record? A medical record is a confidential record that is kept for each patient by a healthcare professional or organisation. It contains the patient's personal details (such as name, address, date of birth), a summary of the patient's medical history, and documentation of each event, including symptoms, diagnosis, treatment and outcome. Relevant documents and correspondence are also included. Traditionally, each healthcare provider involved in a patient's care has kept an independent record, usually paper based. The main purpose of the medical record is to provide a summary of a person's contact with a healthcare provider and treatment provided to ensure appropriate healthcare. Information from medical records also provides the essential data for monitoring patient care, clinical audits and assessing patterns of care and service delivery. In the current environment the medical record also forms the first link in the information chain producing the depersonalised aggregated coded data for statistical purposes. As every health professional, coder, manager and patient knows, considerable effort is invested in writing, filing, sorting, searching, retrieving, issuing and recovering the medical record, in whole or in part. There is no doubt that the ready availability of well organised, legible, accurate and comprehensive clinical notes can play a very significant role in the clinical decision making process and assisting in the provision of quality healthcare.
The Good European Health Record Document ID: Requirements for Clinical Comprehensiveness Version: 1.3 Document Date: 8.1.93 Workpackage: 1-4 2 The Historical Background of Clinical Records Some of the oldest surviving examples of medical recording are papyri from ancient Egypt which contain details of surgery and prescriptions. There has always been a recognised need for those involved in healing or treatment to pass on details of successful procedures or potions either by written methods or through an oral tradition. It is also likely that individual practitioners attempted to describe what they saw and what they did but this was not a widespread practice. The earliest surviving records that describe individual patients in the United Kingdom belong to St Bartholomew’s Hospital and date from its foundation in 1123 AD 1. This was in the reign of Henry I who established the first public records office in England. By the mid nineteenth century individual physicians often kept some notes about their patients but these were usually kept in books according to physician, one book for each year, with the patients filed in alphabetical order. This chronological method of recording meant episodes of illness were considered in isolation. As people became more interested in the cause of illness, the importance of reviewing past events was realised. In 1907 St Mary’s Hospital started a system of unit notes where the patient and not the disease episode became the unit for record compilation. The unit record received extensive development and evaluation at the Presbyterian Hospital in New York where it was implemented in 1916.
In 1969 Weed published a book "Medical records, medical education and patient care“ which introduced a method of structuring a record, the Problem Orientated Medical Record (POMR) 10. This was a format for clinical recording consisting of a problem list, a data base (that is, the history, physical examination and laboratory findings), and then, written out separately for each problem, a plan (diagnostic, therapeutic and educational) and a daily SOAP (subjective, objective, assessment and plan) progress note. The problem list was kept at the front of the medical record and served as an index for the reader so that each problem could be followed through until it was resolved. This system widely influenced note keeping by recognising the four distinct phases of the clinical decision making process: data collection; formulation of problems (not necessarily diagnoses); devising a management plan; reviewing the situation and revising the plan if necessary. However the POMR was not widely adopted exactly as Weed proposed because it proved to be too time consuming. The individual note entries were classified according to problem but were still entered sequentially in date order, making it a time consuming process to acquire a retrospective picture of events within one problem 11 CLICK The electronic health record is a life to death record, containing summary information about key health and healthcare related events. CLICK It will contain some key personal clinical characteristics which don’t change much – if at all - over time. For example blood group, allergies etc CLICK We see the EHR getting populated from a variety of different sources. CLICK So over the life of an individual we can imagine various health, healthcare or life events happening – in early years there will be important information about vaccinations etc. Where there may be a more substantial event takes place – for example a case of appendicitis – then as well as basic information about the event a small block of more detailed information may be attached to the EHR record. CLICK Events continue over time, building up the life to death record.