Medical documentation
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The document discusses different types of medical documentation. Medical documentation refers to written or electronic information about a client's health services and care. It establishes a client's health status, records the care provided, and shows care results. Documentation allows healthcare teams to exchange information. The primary types of documentation discussed are problem-oriented medical records, progress notes, SOAP notes, narrative formats, DAP (data, assessment, plan), and ADIME (assessment, diagnosis, intervention, monitoring, evaluation).
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Medical documentation presentation
1. Medical documentation refers to written or electronic information about a patient's history, examinations, tests, treatments, and outcomes used for evaluation, treatment, communication between providers, research, and legal purposes.
2. The SOAP note format is commonly used and includes subjective information provided by the patient, objective exam findings, an assessment or diagnosis, and a treatment plan.
3. High quality medical documentation is accurate, relevant, complete, timely, and confidential to properly evaluate and care for patients over time.
Medical records
The medical record is a legal document providing a chronicle of a patient's medical history and care.
Medical documentation
This document discusses the importance of proper medical documentation. It begins by defining medical documentation and outlining its key purposes, which include preserving patient information, justifying treatment, allowing for continuity of care, and satisfying regulatory requirements. The document emphasizes that documentation must be accurate, complete, legible, objective, and free of extraneous information. It differentiates between objective clinical findings and subjective patient-reported information. Proper documentation is presented as important for patient care, risk management, and legal protection for medical professionals.
Medical Record Management
The document provides information on the history and development of medical records in India. It notes that Mr. Daniel Gajraj was the first Indian to graduate as a registered medical records librarian in the USA and is considered the father of medical records in India. It also discusses the roles and functions of a medical records department and key components of medical records.
Medical records ppt
The document provides information on medical records including what they are, their components, functions of the medical record department, and processes for receiving, retrieving, completing, and releasing medical records. Some key points:
- Medical records chronicle a patient's medical history and care, including notes, test results, reports, and other documentation entered by healthcare professionals over time.
- Records are used for documenting treatment, communication between providers, collecting health statistics, and legal/insurance matters.
- The medical record department is responsible for filing, retrieving, completing, coding, and evaluating medical records as well as compiling statistics.
- Strict processes are followed for receiving records at discharge or death, retrieving records for care or authorized
Medical record
This document defines a medical record, outlines its uses and purposes, and describes the different forms and documentation standards for medical records. It discusses policies around retention, destruction, and the functions of a medical records department. A medical record contains a patient's health information and is used for continued care, communication between providers, research, and administration. It must be properly documented, including being legible, signed, dated and timed. Policies on medical record retention vary but consider legal requirements and storage costs. The medical records department admits and discharges patients, codes diagnoses, files records, and compiles statistics under the responsibility of the medical records officer.
Medical record and its importance
Medical records are an important system for systematically storing patient information to facilitate access when needed. They contain a patient's personal details, medical history, diagnosis, treatment, and doctors' notes. Well-kept medical records help doctors deliver proper treatment and help patients receive the right care. They also provide important data for research and assessing health services. Nepal has begun developing medical record systems, but they are not yet fully established or standardized across hospitals. Proper medical records are crucial for health planning, research, and delivering quality healthcare services.
Medical documentation
Medical documentation is your proof that you provided good care. It should tell a story, communicate with the healthcare team, explain your medical decision-making, and be able to be used and referenced for medical billing and research. Tips and tricks on how to get this right.
Recommended
Medical documentation presentation
1. Medical documentation refers to written or electronic information about a patient's history, examinations, tests, treatments, and outcomes used for evaluation, treatment, communication between providers, research, and legal purposes.
2. The SOAP note format is commonly used and includes subjective information provided by the patient, objective exam findings, an assessment or diagnosis, and a treatment plan.
3. High quality medical documentation is accurate, relevant, complete, timely, and confidential to properly evaluate and care for patients over time.
Medical records
The medical record is a legal document providing a chronicle of a patient's medical history and care.
Medical documentation
This document discusses the importance of proper medical documentation. It begins by defining medical documentation and outlining its key purposes, which include preserving patient information, justifying treatment, allowing for continuity of care, and satisfying regulatory requirements. The document emphasizes that documentation must be accurate, complete, legible, objective, and free of extraneous information. It differentiates between objective clinical findings and subjective patient-reported information. Proper documentation is presented as important for patient care, risk management, and legal protection for medical professionals.
Medical Record Management
The document provides information on the history and development of medical records in India. It notes that Mr. Daniel Gajraj was the first Indian to graduate as a registered medical records librarian in the USA and is considered the father of medical records in India. It also discusses the roles and functions of a medical records department and key components of medical records.
Medical records ppt
The document provides information on medical records including what they are, their components, functions of the medical record department, and processes for receiving, retrieving, completing, and releasing medical records. Some key points:
- Medical records chronicle a patient's medical history and care, including notes, test results, reports, and other documentation entered by healthcare professionals over time.
- Records are used for documenting treatment, communication between providers, collecting health statistics, and legal/insurance matters.
- The medical record department is responsible for filing, retrieving, completing, coding, and evaluating medical records as well as compiling statistics.
- Strict processes are followed for receiving records at discharge or death, retrieving records for care or authorized
Medical record
This document defines a medical record, outlines its uses and purposes, and describes the different forms and documentation standards for medical records. It discusses policies around retention, destruction, and the functions of a medical records department. A medical record contains a patient's health information and is used for continued care, communication between providers, research, and administration. It must be properly documented, including being legible, signed, dated and timed. Policies on medical record retention vary but consider legal requirements and storage costs. The medical records department admits and discharges patients, codes diagnoses, files records, and compiles statistics under the responsibility of the medical records officer.
Medical record and its importance
Medical records are an important system for systematically storing patient information to facilitate access when needed. They contain a patient's personal details, medical history, diagnosis, treatment, and doctors' notes. Well-kept medical records help doctors deliver proper treatment and help patients receive the right care. They also provide important data for research and assessing health services. Nepal has begun developing medical record systems, but they are not yet fully established or standardized across hospitals. Proper medical records are crucial for health planning, research, and delivering quality healthcare services.
Medical documentation
Medical documentation is your proof that you provided good care. It should tell a story, communicate with the healthcare team, explain your medical decision-making, and be able to be used and referenced for medical billing and research. Tips and tricks on how to get this right.
Medical Records Role and its Maintenance.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
Record Keeping
Record keeping is important for legal protection, memory/communication aid, legal requirements, professional standards of practice, and insurance requirements. Medical records should include specific outlines of patient health histories, be written legibly, use permanent ink or computer records, identify time, date and signature for every entry, describe patient care, findings, changes in condition, and patient/caregiver responses to teaching. Forms in medical records include emergency information, health histories, injury/rehabilitation evaluations, daily treatment forms, and insurance information. Other athletic training/sports medicine records may include budgetary, insurance claims, coaching reports, equipment supply information, personnel information, and student education information. Communication records include what to include in referrals to physicians,
Medical errors
Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
BASIC ABOUT NABH
The document discusses the National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards for healthcare organizations in India. It defines quality from different perspectives and outlines the NABH accreditation process which focuses on patient safety, staff safety, and information/education. The accreditation involves a pre-assessment survey, onsite survey to review documents, facilities, and conduct interviews. It aims to encourage healthcare organizations to improve quality through a peer-review process administered by an independent body based on published standards. Challenges include initial preparation, sustained efforts and resources required for healthcare organizations to fully comply with quality standards.
NABH
This document discusses the National Accreditation Board for Hospitals & Healthcare (NABH) standards for hospital accreditation in India. It provides an overview of NABH, outlines the 10 chapters and over 100 standards that hospitals must meet for accreditation, and gives examples of some key standards within chapters related to access to care, patient care, medication management, patient rights, and quality improvement. The standards are designed to help hospitals improve patient outcomes, safety, and satisfaction by benchmarking their services and processes against internationally recognized quality criteria.
Organization of Medical Record
The document summarizes the organization and importance of medical records in a hospital setting. It discusses the components and flow of medical records, as well as the roles and responsibilities of the medical records department. Key points include that the medical record documents patient care for clinical, legal, and administrative purposes. It outlines the various sections that make up a medical record and how the records move from registration to the central filing unit.
Types of records and common record keeping forms & computerized documenta...
Hospital records are broadly classified into four categories: patient clinical records, individual staff records, ward records, and administrative records. Common record forms include admission nursing history forms, flow sheets, graphic records, patient care summaries, standardized care plans, progress notes, and discharge summary forms. The most common documents in a patient's record are the admission sheet, physician's order sheet, nurse's admission assessment, graphic/flow sheets, medical history and examination, nurses' notes, medication records, progress notes, and diagnostic test results.
Medical Records: Intro, importance, characteristics & issues
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
Medico –legal issues
This document provides information and guidance for doctors on medico-legal cases (MLCs). It discusses what constitutes an MLC, the doctor's responsibilities in managing MLCs, examples of types of cases that would be considered MLCs, procedures for receiving and documenting MLCs, important details to include, and procedures for sample collection and preservation. The document emphasizes that doctors must treat patients first and register cases as MLCs according to the law to avoid legal issues.
NABH
The document discusses NABH (National Accreditation Board for Hospitals and Healthcare Providers) which establishes standards for healthcare organizations in India and provides accreditation. It defines quality healthcare as care that benefits patients without harming them using tested safe and affordable methods according to set standards. NABH accreditation involves an external review of a healthcare organization's quality system and compliance with NABH standards. The standards are divided into patient centered and organization centered standards, covering areas like access to care, patient rights, infection control, management, and information systems. Accreditation through NABH provides benefits to clients, healthcare providers, and healthcare institutions such as improved outcomes, satisfaction, reputation and efficiency.
Quality and patient safety intro
The document discusses the changing role and requirements of hospitals. It notes that hospitals must address increasing chronic diseases, changing public expectations, more patients requiring long-term support, and staff well-being. Hospitals now focus on health promotion for patients and staff, and consider their environmental impact. Performance is measured using data collection, analysis, and evidence-based conclusions to improve quality.
Medical audit
This document provides an overview of medical audit, including:
- Definitions of medical audit and clinical audit
- The history and evolution of audit from the 1850s to modern clinical audit practices
- The need for and benefits of medical audit
- The six stages of the audit process: preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-audit
- Types of clinical audits such as statistical, disease-specific, death, and infection control audits
- Key aspects of implementing a successful audit such as identifying criteria and standards, collecting and analyzing data, and identifying and addressing barriers to change.
Electronic health records
This document discusses the benefits and challenges of electronic health records (EHRs) and their role in public health informatics. It outlines how EHRs can improve patient care by providing more legible, shareable records compared to paper charts. EHRs also enable clinical decision support, alerts, and reminders to help practitioners. On a larger scale, EHR data in clinical data repositories and registries can help public health by tracking diseases, exposures, and procedures. However, EHR adoption faces challenges such as costs, technical issues, security concerns, and lack of standardized data exchange. Overall, the document argues that EHRs have the potential to dramatically change clinical practice and safeguard populations through improved teamwork and surveillance
Medical audit
This document discusses medical audit, including its definition, history, types, stages, principles, and limitations. Some key points:
- Medical audit objectively monitors and evaluates clinical performance to identify opportunities for improvement.
- It began in ancient times but modern clinical audit aims to improve patient outcomes and safety.
- Types of medical audit include statistical, morbidity, postoperative, obstetrics, random case, mortality, and nursing audits.
- Stages include preparing, selecting criteria, measuring performance, making improvements, and sustaining them.
- Principles are defining responsibilities, organizing participation, agreeing programs, and documenting processes/outcomes.
- Limitations include lack of commitment, low participation, imperfect techniques
Hospital information systems - HIS
This presentation gives a glimpse to HIS, EMR and Health Informatics. This is presented by me for clinical service providers.
Medical records
This document summarizes the medical records system at Hindu Rao Hospital in Delhi, India. It describes how the medical records department was established in 1970 with one record keeper and has since expanded. The department now maintains inpatient and outpatient records, compiles statistics, and files records for 10 years. Medical records originate at admission and are assembled, analyzed, and stored by the department. The department also issues birth and death certificates and handles medico-legal tasks like attending courts. It is responsible for collecting utilization data from various departments and compiling monthly reports on topics like communicable diseases and immunizations.
Medical record 20110614
This document discusses the importance of medical record keeping and provides guidance on the key components and structure of a medical record. It emphasizes that the primary purpose of medical records is to serve the physician's memory and communicate information to other providers to facilitate quality patient care. The document outlines the standard sections of a medical record including identification information, chief complaint, history of present illness, past medical history, review of systems, medications, allergies, physical examination, assessment, and plan. It provides details on what should be included in each section to fully document a patient's medical history and care.
Medical council of india guidelines on medical records
1. The Medical Council of India guidelines address key issues around medical record keeping such as maintaining indoor records for 3 years, acknowledging and fulfilling record requests within 72 hours, and computerizing records for quick retrieval.
2. The guidelines recommend retaining inpatient records for 3 years, and outpatient records for 2 years, but records involved in medico-legal cases should be kept until the case is resolved.
3. Medical records are considered admissible and useful evidence in courts for issues like negligence cases, and hospitals have an obligation to produce accurate and complete records when summoned.
Health Information Management Overview
Health information management (HIM) involves various services across multiple healthcare settings including coding, medical records, transcription, chart completion, release of information, and clinical documentation improvement. HIM departments are structured with a director overseeing areas like privacy, compliance, and revenue cycle. Workflows in HIM departments involve managing paper medical records and transitioning to hybrid or electronic systems for chart retrieval, document management, and transcription. Coding clinical data from encounters provides reimbursement through assigned numeric codes.
Healthcare Quality Improvement Tools
This document provides an introduction to various quality improvement tools used in health care, including:
1. Brainstorming, multivoting, and data collection tools to gather input and information.
2. Flow charting and cause-effect diagrams to visualize and analyze processes and potential causes of problems.
3. Pareto diagrams, histograms, and control charts to identify patterns, measure variation, and monitor performance over time.
4. Scatter diagrams to understand correlations between different factors.
The tools can help health care professionals identify issues, uncover root causes of problems, track metrics, and determine if processes are in control or need further improvement.
Problem Oriented Record (POR)
Ringkasan dokumen tersebut adalah:
1. Dokumen tersebut membahas tentang Problem Oriented Medical Record (POR) sebagai sistem dokumentasi keperawatan yang berorientasi pada masalah.
2. POR pertama kali diperkenalkan oleh Dr. Lawrence L. Weed pada tahun 1950-1960.
3. Komponen utama POR antara lain data basis, daftar masalah, rencana awal, dan catatan perkembangan.
Problem oriented medical record
A basic introduction to POMR's Problem oriented medical records.
This is one approach to collect as much data as possible from a patient in order to provide accurate care to a patient. Initally proposed by Dr Lawrence (Larry) Weed this now has become one of the ways information has been collected
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Medical Records Role and its Maintenance.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
Record Keeping
Record keeping is important for legal protection, memory/communication aid, legal requirements, professional standards of practice, and insurance requirements. Medical records should include specific outlines of patient health histories, be written legibly, use permanent ink or computer records, identify time, date and signature for every entry, describe patient care, findings, changes in condition, and patient/caregiver responses to teaching. Forms in medical records include emergency information, health histories, injury/rehabilitation evaluations, daily treatment forms, and insurance information. Other athletic training/sports medicine records may include budgetary, insurance claims, coaching reports, equipment supply information, personnel information, and student education information. Communication records include what to include in referrals to physicians,
Medical errors
Medical errors pose a significant burden globally. While they occur most commonly in hospitals and psychiatric units, with wrong-site surgery being the most frequent issue, they are a preventable ongoing problem. Effective prevention requires multiple coordinated solutions and systems that focus on continually learning from past mistakes, rather than blame, in order to reduce future risks and harm to patients.
BASIC ABOUT NABH
The document discusses the National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards for healthcare organizations in India. It defines quality from different perspectives and outlines the NABH accreditation process which focuses on patient safety, staff safety, and information/education. The accreditation involves a pre-assessment survey, onsite survey to review documents, facilities, and conduct interviews. It aims to encourage healthcare organizations to improve quality through a peer-review process administered by an independent body based on published standards. Challenges include initial preparation, sustained efforts and resources required for healthcare organizations to fully comply with quality standards.
NABH
This document discusses the National Accreditation Board for Hospitals & Healthcare (NABH) standards for hospital accreditation in India. It provides an overview of NABH, outlines the 10 chapters and over 100 standards that hospitals must meet for accreditation, and gives examples of some key standards within chapters related to access to care, patient care, medication management, patient rights, and quality improvement. The standards are designed to help hospitals improve patient outcomes, safety, and satisfaction by benchmarking their services and processes against internationally recognized quality criteria.
Organization of Medical Record
The document summarizes the organization and importance of medical records in a hospital setting. It discusses the components and flow of medical records, as well as the roles and responsibilities of the medical records department. Key points include that the medical record documents patient care for clinical, legal, and administrative purposes. It outlines the various sections that make up a medical record and how the records move from registration to the central filing unit.
Types of records and common record keeping forms & computerized documenta...
Hospital records are broadly classified into four categories: patient clinical records, individual staff records, ward records, and administrative records. Common record forms include admission nursing history forms, flow sheets, graphic records, patient care summaries, standardized care plans, progress notes, and discharge summary forms. The most common documents in a patient's record are the admission sheet, physician's order sheet, nurse's admission assessment, graphic/flow sheets, medical history and examination, nurses' notes, medication records, progress notes, and diagnostic test results.
Medical Records: Intro, importance, characteristics & issues
Unit 1 of MHA SEM- III's syllabus of Medical records Management
(Bharati Vidyapeeth- Center for Health Management Studies & Research, Pune)
Self made- study purpose- reference presentation
avoid hyperlinks on certain slides- inactive
sources shared on last slide as REFERENCES
Hope it helps :)
Medico –legal issues
This document provides information and guidance for doctors on medico-legal cases (MLCs). It discusses what constitutes an MLC, the doctor's responsibilities in managing MLCs, examples of types of cases that would be considered MLCs, procedures for receiving and documenting MLCs, important details to include, and procedures for sample collection and preservation. The document emphasizes that doctors must treat patients first and register cases as MLCs according to the law to avoid legal issues.
NABH
The document discusses NABH (National Accreditation Board for Hospitals and Healthcare Providers) which establishes standards for healthcare organizations in India and provides accreditation. It defines quality healthcare as care that benefits patients without harming them using tested safe and affordable methods according to set standards. NABH accreditation involves an external review of a healthcare organization's quality system and compliance with NABH standards. The standards are divided into patient centered and organization centered standards, covering areas like access to care, patient rights, infection control, management, and information systems. Accreditation through NABH provides benefits to clients, healthcare providers, and healthcare institutions such as improved outcomes, satisfaction, reputation and efficiency.
Quality and patient safety intro
The document discusses the changing role and requirements of hospitals. It notes that hospitals must address increasing chronic diseases, changing public expectations, more patients requiring long-term support, and staff well-being. Hospitals now focus on health promotion for patients and staff, and consider their environmental impact. Performance is measured using data collection, analysis, and evidence-based conclusions to improve quality.
Medical audit
This document provides an overview of medical audit, including:
- Definitions of medical audit and clinical audit
- The history and evolution of audit from the 1850s to modern clinical audit practices
- The need for and benefits of medical audit
- The six stages of the audit process: preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-audit
- Types of clinical audits such as statistical, disease-specific, death, and infection control audits
- Key aspects of implementing a successful audit such as identifying criteria and standards, collecting and analyzing data, and identifying and addressing barriers to change.
Electronic health records
This document discusses the benefits and challenges of electronic health records (EHRs) and their role in public health informatics. It outlines how EHRs can improve patient care by providing more legible, shareable records compared to paper charts. EHRs also enable clinical decision support, alerts, and reminders to help practitioners. On a larger scale, EHR data in clinical data repositories and registries can help public health by tracking diseases, exposures, and procedures. However, EHR adoption faces challenges such as costs, technical issues, security concerns, and lack of standardized data exchange. Overall, the document argues that EHRs have the potential to dramatically change clinical practice and safeguard populations through improved teamwork and surveillance
Medical audit
This document discusses medical audit, including its definition, history, types, stages, principles, and limitations. Some key points:
- Medical audit objectively monitors and evaluates clinical performance to identify opportunities for improvement.
- It began in ancient times but modern clinical audit aims to improve patient outcomes and safety.
- Types of medical audit include statistical, morbidity, postoperative, obstetrics, random case, mortality, and nursing audits.
- Stages include preparing, selecting criteria, measuring performance, making improvements, and sustaining them.
- Principles are defining responsibilities, organizing participation, agreeing programs, and documenting processes/outcomes.
- Limitations include lack of commitment, low participation, imperfect techniques
Hospital information systems - HIS
This presentation gives a glimpse to HIS, EMR and Health Informatics. This is presented by me for clinical service providers.
Medical records
This document summarizes the medical records system at Hindu Rao Hospital in Delhi, India. It describes how the medical records department was established in 1970 with one record keeper and has since expanded. The department now maintains inpatient and outpatient records, compiles statistics, and files records for 10 years. Medical records originate at admission and are assembled, analyzed, and stored by the department. The department also issues birth and death certificates and handles medico-legal tasks like attending courts. It is responsible for collecting utilization data from various departments and compiling monthly reports on topics like communicable diseases and immunizations.
Medical record 20110614
This document discusses the importance of medical record keeping and provides guidance on the key components and structure of a medical record. It emphasizes that the primary purpose of medical records is to serve the physician's memory and communicate information to other providers to facilitate quality patient care. The document outlines the standard sections of a medical record including identification information, chief complaint, history of present illness, past medical history, review of systems, medications, allergies, physical examination, assessment, and plan. It provides details on what should be included in each section to fully document a patient's medical history and care.
Medical council of india guidelines on medical records
1. The Medical Council of India guidelines address key issues around medical record keeping such as maintaining indoor records for 3 years, acknowledging and fulfilling record requests within 72 hours, and computerizing records for quick retrieval.
2. The guidelines recommend retaining inpatient records for 3 years, and outpatient records for 2 years, but records involved in medico-legal cases should be kept until the case is resolved.
3. Medical records are considered admissible and useful evidence in courts for issues like negligence cases, and hospitals have an obligation to produce accurate and complete records when summoned.
Health Information Management Overview
Health information management (HIM) involves various services across multiple healthcare settings including coding, medical records, transcription, chart completion, release of information, and clinical documentation improvement. HIM departments are structured with a director overseeing areas like privacy, compliance, and revenue cycle. Workflows in HIM departments involve managing paper medical records and transitioning to hybrid or electronic systems for chart retrieval, document management, and transcription. Coding clinical data from encounters provides reimbursement through assigned numeric codes.
Healthcare Quality Improvement Tools
This document provides an introduction to various quality improvement tools used in health care, including:
1. Brainstorming, multivoting, and data collection tools to gather input and information.
2. Flow charting and cause-effect diagrams to visualize and analyze processes and potential causes of problems.
3. Pareto diagrams, histograms, and control charts to identify patterns, measure variation, and monitor performance over time.
4. Scatter diagrams to understand correlations between different factors.
The tools can help health care professionals identify issues, uncover root causes of problems, track metrics, and determine if processes are in control or need further improvement.
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Types of records and common record keeping forms & computerized documenta...
Types of records and common record keeping forms & computerized documenta...
Medical Records: Intro, importance, characteristics & issues
Medical Records: Intro, importance, characteristics & issues
Medical council of india guidelines on medical records
Medical council of india guidelines on medical records
Viewers also liked
Problem Oriented Record (POR)
Ringkasan dokumen tersebut adalah:
1. Dokumen tersebut membahas tentang Problem Oriented Medical Record (POR) sebagai sistem dokumentasi keperawatan yang berorientasi pada masalah.
2. POR pertama kali diperkenalkan oleh Dr. Lawrence L. Weed pada tahun 1950-1960.
3. Komponen utama POR antara lain data basis, daftar masalah, rencana awal, dan catatan perkembangan.
Problem oriented medical record
A basic introduction to POMR's Problem oriented medical records.
This is one approach to collect as much data as possible from a patient in order to provide accurate care to a patient. Initally proposed by Dr Lawrence (Larry) Weed this now has become one of the ways information has been collected
Documenting And Reporting
The document discusses documentation and reporting in nursing. It defines documentation as a permanent record of client information and care, while reporting involves sharing client care information between two or more people. The importance of documenting and reporting for communication, legal purposes, research, education, and quality assurance is explained. Common documentation methods like source-oriented records, problem-oriented records, narrative notes, and computerized charting are described. Guidelines for effective documentation including brevity, accuracy, appropriateness, completeness and confidentiality are also provided.
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Introduction to Medical records and Documentation revised 01-13
This document provides guidance on navigating a medical record to find pertinent patient information. It outlines the typical sections of a medical record including the initial physician assessment, progress notes, nursing notes, labs, medications, radiology reports, and documentation from other healthcare professionals. It emphasizes the importance of accurate and thorough documentation in medical records for legal and care purposes. Common documentation formats like SOAP, narrative, and problem-oriented records are also overviewed.
Documentation and Reporting
The document discusses documentation and reporting in healthcare. It defines documentation as a permanent record of client information and care. Documentation serves several purposes such as communication between providers, legal documentation, research, and education. The document outlines various methods of documentation including narrative charting, problem-oriented charting, and computerized documentation. It also discusses different types of records like the kardex, flow sheets, and discharge summary used for recording client data. Verbal reporting is also an important communication technique in healthcare.
Records.ppt
Records and reports at the community level provide important health information. Records include individual health cards, family folders, community folders, and national health program records. They are categorized by type (e.g. periodic, unit-based), subject (e.g. medical, social), and collection place (e.g. health centers, with individuals). Important records kept at health centers include family folders, MCH cards, and treatment/referral records. Records kept with patients include health cards and medicine stock registers. Maintaining accurate, organized records and reports is essential for assessing community health, collecting data, planning, and conducting research.
RECORDS & REPORTS
The document defines records and reports, providing principles for maintaining accurate records. It describes different types of records like clinical records, staff records, and administrative records. Records are used for communication, diagnosis, education, research and legal documentation. Reports summarize services and are used for communication, planning, and interpreting services. Different types of reports like 24-hour reports and census reports are described. The responsibilities of nurses in accurate record keeping and reporting are also outlined.
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This document discusses pharmaceutical care, which aims to improve patient outcomes through responsible drug therapy. It defines pharmaceutical care as providing medication to achieve therapeutic outcomes that enhance quality of life. These may include curing disease, reducing symptoms, or slowing disease progression. The document outlines the basic elements of pharmaceutical care, which include being patient-oriented, addressing both acute and chronic issues, and emphasizing prevention of drug-related problems through documented care plans and collaboration with other providers. It also discusses various tools used in pharmaceutical care, such as SOAP notes, CORE pharmacotherapy plans, and FARM analyses to identify, resolve, and prevent drug-related issues.
SOAP Notes: Getting Down and Dirty with Medical Translation
Progress notes and patient records are the medical translator's bread and butter, but this doesn't prevent even the most experienced medical translators from getting burnt. We'll take a closer look at the SOAP (Subjective, Objective, Assessment, Plan) format to understand how doctors think. We'll use the tool to understand why "BS" could mean "blood sugar," "breath sounds," or "bowel sounds." We'll also build a kit of multilingual resources for the review of systems, lab reports, etc. Finally, we'll address capturing succinct source-language style in a translation that is meaningful and not unduly conservative.
Recording & reporting
The document discusses guidelines for proper documentation and reporting in healthcare, including maintaining accurate, complete records for communication, education, and legal purposes. It also outlines the different types of reports like change of shift reports, incident reports, and legal reports that are important for monitoring quality of care. Proper documentation in medical records is essential for continuity of care, research, and evaluating health programs.
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On the other hand, a Clinical Statistical Programmer performs all the procedures to generate future outputs and makes advanced and real-world developments to face further challenges. A primary role of Clinical Statistical Programmers is to use their technical and programming skills in order to enable clinical trial statisticians to perform their statistical analysis duties more efficiently.
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Data integrity issues are regularly cited by global regulatory agencies in inspection reports. National cultures can influence compliance with data integrity standards due to differences in power distance, individualism, and time orientation. Regulators now specifically target data integrity during inspections and audit raw data to verify submitted information. Companies must consider cultural factors when ensuring global compliance and promote quality cultures through codes of conduct.
E04733639
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Review on Medical Reports Extraction and Storage in EHR systems
This document reviews different tools and techniques for extracting data from medical reports and storing the extracted data in databases. It discusses using optical character recognition (OCR) to extract text from image-based medical reports and PDF parsers to extract text from PDF reports. The document examines several papers that have tested different OCR tools like Tesseract, Amazon Textract, and Google Document AI on medical report datasets. It also reviews methods for preprocessing medical report images to improve OCR accuracy and discusses challenges in extracting data from the semi-structured format of medical reports. Finally, it covers approaches for storing extracted medical data in databases and analyzing the data.
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The GEHR structure is very comprehensive, data items being stored in a number of related tables that are held in a MS Access database. The software for the system has been developed in Microsoft Visual C++ and when combined with the database, it provides an application that is fast and well integrated with the Windows environment. Development of the system has followed a stepwise approach with validation of the architecture and the incorporation of feedback from users at each key stage.
There are five major work areas: patient records, reports, graphs, Diabetes Aggregated Data (DAD) and administration. Each of these contains a number of individual application/functions which are serviced by the relational tables that store the patient details, clinical measurements, doctors and user information. The Patient Records Function offers options for the management of the EHCRs (creation/correction/visualisation), such as: registration of a new patient and entry of the first record or sheet; the recording of a new sheet; the correction/visualisation of the sheet; the recording of data about the patient’s death, etc. The System Administration Function allows: Definition of the health care facility; definition of persons as users or system managers; management of passwords and access rights for the users; definition of measurement units; limited customisation of the user interface.
Overview of ePRO
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Barbara Marino, PhD, RN
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The document describes a healthcare management system that will maintain medical histories of patients, employees, and dependents. It will track medicine stock and issuance using inventory management. The system requires initial entry of master data that is rarely changed. Medical histories reference this master data, and patient/dependent information is automatically retrieved using a registration number. The document outlines the process for treatment, including generating medical slips, doctor examination, prescriptions, pharmacy medicine issuance, referrals, and stock tracking. It lists reports like medical examination history, test results, lists of providers, and master data screens for areas, ailments, specialties, and more.
Health care management system
The document describes a healthcare management system that will maintain medical histories of patients, employees, and dependents. It will track medicine stock and issuance using inventory management. The system requires initial entry of master data that is rarely changed. Medical histories reference this master data, and patient/dependent information is automatically retrieved using a registration number. The document outlines the process for treatment, including generating medical slips, doctor examination, prescriptions, pharmacy medicine issuance, referrals, and stock tracking. It lists reports like medical examination history, test results, lists of providers, and master data screens for areas, ailments, specialties, and more.
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Medical documentation
- 1. 11 Medical DocumentationMedical Documentation QURATULAIN MUGHALQURATULAIN MUGHAL BATCH IVBATCH IV IIRSIIRS
- 2. 2 Medical DocumentationMedical Documentation Medical documentation refers to anyMedical documentation refers to any written or electronically generatedwritten or electronically generated information about a client describinginformation about a client describing services or care provided to thatservices or care provided to that client.client.
- 3. 3 Electronic documentsElectronic documents Electronic documents includeElectronic documents include computer created medical recordcomputer created medical record files, faxes, e-mails, pictures, videofiles, faxes, e-mails, pictures, video or audio recordings.or audio recordings.
- 4. 4 PurposePurpose The primary purpose of medicalThe primary purpose of medical documentation is to establish thatdocumentation is to establish that individual's health status and need forindividual's health status and need for care, record the care given, andcare, record the care given, and demonstrate the results of the care.demonstrate the results of the care. Medical documentation allows for theMedical documentation allows for the exchange of information between allexchange of information between all members of the healthcare team.members of the healthcare team. The health record provides legal proof ofThe health record provides legal proof of the type of care the patient received andthe type of care the patient received and that person's response to that care.that person's response to that care.
- 5. 5 TYPES OF MEDICAL RECORDTYPES OF MEDICAL RECORD DOCUMENTATIONDOCUMENTATION There are various forms of medical recordThere are various forms of medical record documentation :documentation : PROBLEM ORIENTED MEDICALPROBLEM ORIENTED MEDICAL RECORD(POMR)RECORD(POMR) PROGRESS NOTEPROGRESS NOTE SOAPSOAP NARRATIVE FORMATNARRATIVE FORMAT DAP (DATA, ASSESSMENT, PLAN)DAP (DATA, ASSESSMENT, PLAN) ADIME (Assessment, DiagnosisADIME (Assessment, Diagnosis Intervention, Monitoring, Evaluation)Intervention, Monitoring, Evaluation)
- 6. 6 PROBLEM ORIENTED MEDICALPROBLEM ORIENTED MEDICAL RECORD(POMR)RECORD(POMR) A system of collection data thatA system of collection data that focuses on the primary clientfocuses on the primary client problems.problems. A problem list is generated,A problem list is generated, updated, and continually reviewedupdated, and continually reviewed
- 7. 7 PROGRESS NOTEPROGRESS NOTE Often a brief notation as a follow upOften a brief notation as a follow up to an original assessment.to an original assessment. This note will review the problem,This note will review the problem, evaluate the effectiveness of plan,evaluate the effectiveness of plan, and indicate change.and indicate change. Progress notes are documented atProgress notes are documented at pre-established intervals (daily, twicepre-established intervals (daily, twice a week, monthly, etc)a week, monthly, etc)
- 8. 8 SOAPSOAP Acronym for Subjective, Objective,Acronym for Subjective, Objective, Assessment, Plan.Assessment, Plan. Many physicians and health careMany physicians and health care providers document in this formatproviders document in this format and it is easy to follow.and it is easy to follow. Some facility use pre-printed formsSome facility use pre-printed forms and practitioners fill out the blanks.and practitioners fill out the blanks. Others simply provide lined sheetsOthers simply provide lined sheets that the provider will simply writethat the provider will simply write out .out .
- 9. 9 NARRATIVE FORMATNARRATIVE FORMAT The provider writes out informationThe provider writes out information about the patient in an organizedabout the patient in an organized way (similar data clusteredway (similar data clustered together).together). Often this is in long phrases orOften this is in long phrases or sentences reviewing the patient’ssentences reviewing the patient’s problems.problems.
- 10. 10 DAP (DATA, ASSESSMENT,DAP (DATA, ASSESSMENT, PLAN)PLAN) Similar to SOAP but without theSimilar to SOAP but without the subjective component (all data,subjective component (all data, whether subjective or objective iswhether subjective or objective is clustered together)clustered together)
- 11. 11 ADIME (Assessment,DiagnosisADIME (Assessment,Diagnosis Intervention,Monitoring,Evaluation )Intervention,Monitoring,Evaluation ) This type of charting follows theThis type of charting follows the Nutrition Care Process steps FacilitiesNutrition Care Process steps Facilities may decide to order notes in thismay decide to order notes in this format OR address the initialformat OR address the initial problem of the patient (in acuteproblem of the patient (in acute care)care)
- 12. 12