information law and governance in clinical practice 12.9.23.pptxnaveenithkrishnan
Clinical governance is the set of relationships and responsibilities established by a health service organisation between its state or territory department of health, governing body, executive, workforce, patients, consumers and other stakeholders to ensure good clinical outcomes.
information law and governance in clinical practice 12.9.23.pptxnaveenithkrishnan
Clinical governance is the set of relationships and responsibilities established by a health service organisation between its state or territory department of health, governing body, executive, workforce, patients, consumers and other stakeholders to ensure good clinical outcomes.
Principles of Health Informatics: Informatics skills - communicating, structu...Martin Chapman
Principles of Health Informatics: Informatics skills - communicating, structuring, and questioning. Last delivered in 2023. All educational material listed or linked to on these pages in relation to King's College London may be provided for reference only, and therefore does not necessarily reflect the current course content.
An electronic medical record includes information about a patient's health history, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans.
This is a simple presentation about Hospital Information System. The following are the contents.
1) What is Hospital Information System?
2) Problems associated with traditional paper based systems.
3) Purpose of Hospital Management System
4) Functions
5) How it works?
6) System Requirements
7) Advantages
This is my first upload, hope you like it.
This presentation talks about the context of developing the Electronic Health records for India. the guidelines as mentioned in the GOI site is described vividly with examples, for better understanding.
N.B: Please download the ppt first, for the animations to work better.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
This is an overview on the organization andd function of the medical records department in a hospital. It would be of help to administrators and planners, as well as for teachers.
Principles of Health Informatics: Informatics skills - communicating, structu...Martin Chapman
Principles of Health Informatics: Informatics skills - communicating, structuring, and questioning. Last delivered in 2023. All educational material listed or linked to on these pages in relation to King's College London may be provided for reference only, and therefore does not necessarily reflect the current course content.
An electronic medical record includes information about a patient's health history, such as diagnoses, medicines, tests, allergies, immunizations, and treatment plans.
This is a simple presentation about Hospital Information System. The following are the contents.
1) What is Hospital Information System?
2) Problems associated with traditional paper based systems.
3) Purpose of Hospital Management System
4) Functions
5) How it works?
6) System Requirements
7) Advantages
This is my first upload, hope you like it.
This presentation talks about the context of developing the Electronic Health records for India. the guidelines as mentioned in the GOI site is described vividly with examples, for better understanding.
N.B: Please download the ppt first, for the animations to work better.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
This is an overview on the organization andd function of the medical records department in a hospital. It would be of help to administrators and planners, as well as for teachers.
How to Make Awesome SlideShares: Tips & TricksSlideShare
Turbocharge your online presence with SlideShare. We provide the best tips and tricks for succeeding on SlideShare. Get ideas for what to upload, tips for designing your deck and more.
Patient Record System (Electronic Medical Records).pptxmamtabisht10
Electronic Medical Records also known as Patient record system is the digital version of the clinical information regarding a patient.
It involves collecting, storing, manipulating and using the available clinical information in delivering care to the patient.
Pg2 Beginning in 1991, the IOM (which stands for the Institute o.docxrandymartin91030
Pg2 Beginning in 1991, the IOM (which stands for the Institute of Medicine of the National Academies) sponsored studies and created reports that led the way toward the concepts we have in place today for electronic health records. Originally, the IOM called them computer-based patient records.1 During their evolution, the EHR have had many other names, including electronic medical records, computerized medical records, longitudinal patient records, and electronic charts. All of these names referred to essentially the same thing, which in 2003, the IOM renamed as the electronic health records, or EHR.
Note: EHR
The acronym EHR is commonly used as shorthand for Electronic Health Records, and will be used in the remainder of this book.
Institute of Medicine (IOM)
The IOM report2 put forth a set of eight core functions that an EHR should be capable of performing:
Health information and data
This function provides a defined data set that includes such items as medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results. Further, it provides improved access to information needed by care providers when they need it.
Result management
Computerized results can be accessed more easily (than paper reports) by the provider at the time and place they are needed.
· Reduced lag time allows for quicker recognition and treatment of medical problems.
· The automated display of previous test results makes it possible to reduce redundant and additional testing.
· Having electronic results can allow for better interpretation and for easier detection of abnormalities, thereby ensuring appropriate follow-up.
· Access to electronic consults and patient consents can establish critical links and improve care coordination among multiple providers, as well as between provider and patient
Order management
Computerized provider order entry (CPOE) systems can improve workflow processes by eliminating lost orders and ambiguities caused by illegible handwriting, generating related orders automatically, monitoring for duplicate orders, and reducing the time required to fill orders.
· CPOE systems for medications reduce the number of errors in medication dose and frequency, drug allergies, and drug–drug interactions.
· The use of CPOE, in conjunction with an EHR, also improves clinician productivity.
Decision Support
Computerized decision support systems include prevention, prescribing of drugs, diagnosis and management, and detection of adverse events and disease outbreaks.
· Computer reminders and prompts improve preventive practices in areas such as vaccinations, breast cancer screening, colorectal screening, and cardiovascular risk reduction.
Electronic communication and connectivity
Electronic communication among care partners can enhance patient safety and quality of care, especially for patients who have multiple providers in multiple settings that must coordinate care plans.
· Electronic co.
With all the focus on Healthcare. Lowering costs, Out-sourcing. Generic drugs. HL7 & HIPAA getting the bigger picture and ensuring SOCIAL and BUSINESS needs are merged is important. Corporate Social Responsibility, Ethics, Values, Transparency ALONG with Business, Revenue, Profit, Patents, Trade-secrets & IPR.
What you need to know about Meaningful Use 2 & interoperabilityCompliancy Group
Does this describe you?
·You are constantly challenged to stay abreast of the latest information on EHR integration and HIE interoperability, Meaningful Use stages, the Direct Project, clinician and patient portals, just to name a few.
·You walk a fine line between adopting health information technology for the good it can bring patient outcomes…….and for the good incentive dollars it can mean to your organization.
·You play a key role in ensuring your organization can attest for meaningful use.
Join Andy Nieto, Health IT Strategist at DataMotion where he’ll explain the key role that interoperability plays in Meaningful Use Stage 2 attestation including:
- What does interoperability really mean
- Why you can’t ignore interoperability
- How to achieve interoperability and make it meaningful
- What you need in order to attest
eHealth Practice in Europe: where do we stand?chronaki
eHealth as the use of Information and communication technologies in the practice of health care comprises Electronic health records, Healthcare information exchange cross-jurisdictions, Personal health records, Telehealth, telemedicine and remote monitoring.
There are several efforts to reflect and measure the practice of eHealth including efforts by the OECD and WHO, but in general there is little reported sharing of health data particularly with patients. Specific barriers frequently mentioned are supporting policies and coherent widely implemented standards.
The presentation discusses relevant efforts and programs supported by the European Commission such as the eHealth DSI, eStandards, ASSESS CT, and openMedicine aiming at large scale eHealth adoption It calls for engagement of European Society, its national societies, and its members.
Electronic Health Records: purpose of electronic health records, popular electronic health record system, advantages of electronic records, challenges of electronic health records, the key players involved.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
2. THE MEDICAL RECORD
The medical record is an important document that must contain
sufficient data to identify the patient, support the diagnosis or
reason for attendance at the health care facility, justify the
treatment and accurately document the results of that treatment”
The main purpose of the medical record is:
• to record the facts about a patient's health with emphasis on
events affecting the patient during the current admission or
attendance at the health care facility, and for the continuing care
of the patient when they require health care in the future.
3. ELECTRONIC HEALTH RECORDS DEFINED
What is Electronic Health Records (EHR):
: contains all personal health information belonging to an
individual, entered and accessed electronically by healthcare
providers which extends beyond acute in-patient encounters
including all ambulatory care settings at which a patient receives
care.
: is an official health record for an individual that is shared among
multiple facilities and agencies. There are government incentives in
many countries to standardize EHRs and ensure that every citizen
has one.
4. ELECTRONIC MEDICAL RECORDS
What is Electronic Medical Records (EMR):
: is a digital version of the traditional paper-based medical record
for an individual. The EMR represents a medical record within a
single facility, such as a doctor's office or a clinic. It is a computer
system that records patient’s demographics and medical data for
long-term storage and analysis.
5. RETENTION PERIOD FOR MEDICAL
RECORDS IN THE PHILIPPINES
Retention Period for Patient Records as stated in DOH Circular No.
70, S. 1996.
• 15 years retention period – in patient records
• 10 years retention period – out patient records from date of last
visit
6. ISSUES AND CHALLENGES IN MEDICAL
RECORDS
1. Legibility of entries
2. Lack of standard terminologies (ICD 10 terminologies
for Diagnosis and CPT procedure codes terminologies)
3. Incomplete documentation
4. Manual consolidation of reports
5. Filing space for patient records
6. Access to Health Records anytime, anywhere in a secured
manner
7. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
1. INTEROPERABILITY OF SYSTEMS/STANDARDS
INTEROPERABILITY is defined as the ability of two or more systems or
components to exchange information and use the information that has been
exchanged.
• Information communication is a key component in any system. Effective
communication requires that information senders and receivers share a
common “reference framework” that enables all interactions to be
understood. Standards provides this common framework, promoting
uniformity in the definition and identification of health system components,
whether objects, diagnosis, people and intervention.
• Syntactic or Functional – structure of a communication
• Semantics – holds the meaning of a communication
8. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
1. INTEROPERABILITY OF SYSTEMS
A Controlled Vocabulary is a key component in achieving the interoperability of health
information system, this does not only facilitate system interoperability but also enable statistical
and epidemiological analysis, reports for computer assisted decision-making, planning of care
and follow-up strategies.
Importance of Controlled Vocabularies
• Standardizing free text or structured contents of the medical record
• Representing clinical observations and evaluations
• Coding tests and results
• Identifying drugs
• Interchanging clinical data in real time
• Representing syntactic and semantic aspects of medical concepts
• Recovering and analyzing data, and supporting the decision-making process
9. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
1. INTEROPERABILITY OF SYSTEMS
Examples of Controlled Vocabularies:
SNOMED CT
LOINC
DRG
ICD 10
CPT
NDC & Rx Norm
10. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
2. PRIVACY AND CONFIDENTIALITY OF INFORMATION
• Assurance of the confidentiality and privacy of data, laws that must
cover the EHR.
• Data Privacy Act of 2012 or Republic Act 10173
3. Implementation guidelines in Electronic Health Records
• Philippine Health Information Exchange
• Administrative Orders and Circulars from Regulatory Agencies
• E-Commerce Law or Republic Act 8792 – is healthcare included in
the digital information processing included?
11. ISSUES AND CHALLENGES IN ELECTRONIC
HEALTH RECORDS
4. Technology Infrastructure
• Internet connectivity stability
• Redundancy of Storage must be defined
• Disaster Recovery Plan
• Systems Security
5. Risk Management
6. Change Management
