IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
A personal health record (PHR) is an electronic application that allows patients to maintain and manage their health information privately. A PHR contains a patient's medical history and health data, such as lab results, that can be accessed online. PHRs can be paper-based, computer-based, web-based, or accessible through portable devices. PHRs provide benefits like improving patient engagement, coordinating information from multiple healthcare providers, ensuring information is available during emergencies, reducing administrative costs, encouraging family health management, enhancing patient-provider communication, and allowing patients to track and manage their health.
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.
Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Me...emallin
The document discusses improving the timeliness and quality of discharge summaries dictated by internal medicine residents. It describes challenges with current discharge summaries and studies showing delays in availability and poor quality can contribute to adverse events. An educational intervention was instituted along with a same-day discharge process, which improved the timeliness of discharge summaries without compromising quality. Preliminary results also showed the educational intervention improved completeness scores of discharge summaries, though not statistically significantly, and did not affect readability.
The document discusses key concepts in developing a Management Information System (MIS) for a hospital. It outlines the components and modules of an MIS, including collecting data on patient registration, admissions/discharges, operating theaters, laboratories, and finances. The summary describes how an MIS helps monitor performance indicators like mortality/morbidity rates, bed occupancy rates, infection rates, and average length of stay to analyze the efficiency and quality of health services. Developing relevant indices and comparing them to norms allows hospitals to identify issues and make improvements.
This document discusses medical audits and provides information on various types of audits including internal and external audits, managerial/organizational audits, medical/clinical audits, and financial audits. It explains the need for audits to maintain safety, quality, reputation and funding. The document outlines the six stages of clinical audits including preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-auditing. Methods used in audits like direct observation, checklists, documentation reviews, questionnaires and interviews are also mentioned.
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 audit is a systematic evaluation of medical care to improve patient outcomes. It involves reviewing medical records against criteria to identify areas for improvement. The key aspects that can be audited include structure, processes, and outcomes of care. Medical audit aims to ensure best possible care, evidence-based practice, and implementation of initiatives. It benefits patients through reduced suffering and ensures safety. Hospitals should establish medical audit committees and collect data to facilitate the audit process. Audits help practitioners identify weaknesses and make corrections to enhance quality of care.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
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 :)
A personal health record (PHR) is an electronic application that allows patients to maintain and manage their health information privately. A PHR contains a patient's medical history and health data, such as lab results, that can be accessed online. PHRs can be paper-based, computer-based, web-based, or accessible through portable devices. PHRs provide benefits like improving patient engagement, coordinating information from multiple healthcare providers, ensuring information is available during emergencies, reducing administrative costs, encouraging family health management, enhancing patient-provider communication, and allowing patients to track and manage their health.
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.
Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Me...emallin
The document discusses improving the timeliness and quality of discharge summaries dictated by internal medicine residents. It describes challenges with current discharge summaries and studies showing delays in availability and poor quality can contribute to adverse events. An educational intervention was instituted along with a same-day discharge process, which improved the timeliness of discharge summaries without compromising quality. Preliminary results also showed the educational intervention improved completeness scores of discharge summaries, though not statistically significantly, and did not affect readability.
The document discusses key concepts in developing a Management Information System (MIS) for a hospital. It outlines the components and modules of an MIS, including collecting data on patient registration, admissions/discharges, operating theaters, laboratories, and finances. The summary describes how an MIS helps monitor performance indicators like mortality/morbidity rates, bed occupancy rates, infection rates, and average length of stay to analyze the efficiency and quality of health services. Developing relevant indices and comparing them to norms allows hospitals to identify issues and make improvements.
This document discusses medical audits and provides information on various types of audits including internal and external audits, managerial/organizational audits, medical/clinical audits, and financial audits. It explains the need for audits to maintain safety, quality, reputation and funding. The document outlines the six stages of clinical audits including preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-auditing. Methods used in audits like direct observation, checklists, documentation reviews, questionnaires and interviews are also mentioned.
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 audit is a systematic evaluation of medical care to improve patient outcomes. It involves reviewing medical records against criteria to identify areas for improvement. The key aspects that can be audited include structure, processes, and outcomes of care. Medical audit aims to ensure best possible care, evidence-based practice, and implementation of initiatives. It benefits patients through reduced suffering and ensures safety. Hospitals should establish medical audit committees and collect data to facilitate the audit process. Audits help practitioners identify weaknesses and make corrections to enhance quality of care.
Medical Records: Intro, importance, characteristics & issuesSrishti Bhardwaj
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 :)
The document discusses patient care and monitoring systems. It provides details on the HELP system at LDS Hospital, which was one of the first and most successful clinical information systems. The HELP system evolved from initially providing decision support during care to also supporting nursing care decisions and aggregating data for research. It has been in continuous operation since 1967 and integrated into multiple hospitals. Evaluations found that the HELP system was widely accepted, demonstrated the feasibility of computerized clinical decision support, and provided improvements in patient care and more cost-effective care.
Medical record formats can be organized in different ways. The three main formats are: source oriented, integrated, and problem oriented. Source oriented arranges information by source like nurses, doctors, etc. Integrated files all documents in chronological order regardless of source. Problem oriented focuses on documenting care by identifying and tracking the resolution of patient problems.
There are two main functions of veterinary medical records: 1) to support patient medical care by documenting diagnoses, procedures, treatments, and responses; and 2) for secondary purposes like evaluations, legal/research use, and assessing staffing/finances. Medical records must be complete and accurate to defend against malpractice suits and help determine insurance claims. The most widely used format is the problem-oriented veterinary medical record (POVMR), which commonly includes client information, history, exams, problem lists, notes, forms, and summaries.
Medico Legal implication of medical records-IndiaSrishti Bhardwaj
Medico legal liabilities related to patient records,
Medical Record committee and role of committee Hospital Utilization
Bed turnover ratio,
Average length of stay,
Death rate,
Bed occupancy rate
Unit 4- BVUCHMSR Portion (Sem-3)
Types of records and common record keeping forms & computerized documenta...Siva Nanda Reddy
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.
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.
The document discusses the planning and organization of a medical records department in a hospital. It begins by defining medical records and outlining their purposes for patients, doctors, hospitals, and research. It then describes how to plan and organize the department, including establishing sections for admissions, central records, and outpatient records. Staffing requirements are provided for a 500-bed hospital. Physical facility needs are also outlined. The document concludes by explaining the process of medical record flow upon patient admission.
This document outlines the goals and organization of a medical record management department. The key points are:
1) Medical records are essential for patient care, research, and healthcare planning. Accurate records are needed to evaluate care quality and access health status.
2) The goals of the medical records department are to maintain high quality records, generate health information, ensure care quality, protect privacy, and support various uses including research, policy, and legal/insurance needs.
3) The department is overseen by a Medical Records Officer and organizes registration, audits, forms, and work distribution to achieve effective records management.
How Can Hospitals Improve Their Patient Referral Management By Complying With...GaryRichards30
Meaningful use (MU) is a set of standards that defines criteria for electronic health records (EHR) and their effective use through activities like clinical data exchange between providers. The document discusses how hospitals can meet MU standards to qualify for incentive payments and avoid penalties by using patient referral management systems that integrate with their EHRs. Such integrated systems allow secure sharing of patient data, tracking of referral timelines and statuses, managing referral workflows, and analytics on referral patterns.
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.
A critical analysis of purchasing arrangements under BPJS in Indonesiaresyst
This document summarizes a presentation on strategic purchasing arrangements under Indonesia's National Health Insurance program (BPJS). It outlines the country's transition to universal health coverage through BPJS, describes the key actors and financing mechanisms, and identifies gaps and challenges, including unclear roles and accountability between BPJS and the Ministry of Health, limited data and monitoring capacity, problems with incentive structures, and inadequate resources and capacity at BPJS to effectively manage the program and monitor providers. Recommendations include strengthening collaboration between central and local governments, public reporting on performance, and reforming BPJS's management culture.
Introduction to Medical records and Documentation revised 01-13kbpennington
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.
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.
This document provides information on various pharmacy records and reports that must be maintained, including controlled substance inventory, medication orders, manufacturing records, purchase records, and workload records. It discusses the importance of accurate prescription filing records for both legal and patient care purposes. An example drug profile on Duloxetine is presented, outlining its description, indications, contraindications, warnings, dosage, and adverse effects. The document also discusses patient medication profiles and examples of drug interaction related to absorption, distribution, metabolism, and excretion.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
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.
Hospital Statistics and Pabon Lasso Model of Hospital Performance Measurement Zulfiquer Ahmed Amin
This document discusses key concepts and definitions related to hospital statistics. It defines key terms like data, information, statistics, hospital statistics, admission, discharge, bed occupancy rate, length of stay, and more. It also describes different types of hospital statistics reports including those related to beds, admissions, workload, and care evaluation. The uses and importance of collecting and analyzing hospital statistics are outlined.
Medical Record system: training to staff, maintenance & Retention & StorageSrishti Bhardwaj
Developing recording system in the hospital:
Maintaining adequate records on the patient file,
Training programs for staff,
*Retention and storing of medical Records*:
Outpatient,
Inpatient,
Medico legal cases retention policies,
process of medical record storing
The document discusses the health record system at the National Cancer Institute in Malaysia. It involves using electronic medical records (EMR) and the FiSiCien system to improve patient care. Patient records are stored securely using a Terminal Digit system and manual filing with pocket files. Records are retrieved upon request for purposes like insurance claims but charges apply. The system aims to complete records within 30 days and properly dispose of records after 7 years.
Courts are rapidly becoming a gold mine of information for private companies that re-sell case information for such purposes as credit, criminal record, and rental history checks. This session will address issues surrounding the use of court information for public purposes, including what information should be available to non-parties, who is responsible for ensuring its accuracy, whether courts should charge for access and on what basis, and how long information should be available?
Develop, Test and Deploy your SOA Application through a Single PlatformWSO2
WSO2 Carbon Studio is a development tool that allows users to develop, test, and deploy SOA applications on the WSO2 Carbon platform through a single integrated environment. The Carbon platform provides capabilities like service hosting, message mediation, data access, security, and process orchestration. Carbon Studio supports developing various service types, mediation configurations, data services, registry resources, and business processes. It allows deploying applications to local and remote Carbon servers for debugging and testing purposes. Carbon Studio aims to provide a one stop solution for the entire SOA application lifecycle.
The document discusses patient care and monitoring systems. It provides details on the HELP system at LDS Hospital, which was one of the first and most successful clinical information systems. The HELP system evolved from initially providing decision support during care to also supporting nursing care decisions and aggregating data for research. It has been in continuous operation since 1967 and integrated into multiple hospitals. Evaluations found that the HELP system was widely accepted, demonstrated the feasibility of computerized clinical decision support, and provided improvements in patient care and more cost-effective care.
Medical record formats can be organized in different ways. The three main formats are: source oriented, integrated, and problem oriented. Source oriented arranges information by source like nurses, doctors, etc. Integrated files all documents in chronological order regardless of source. Problem oriented focuses on documenting care by identifying and tracking the resolution of patient problems.
There are two main functions of veterinary medical records: 1) to support patient medical care by documenting diagnoses, procedures, treatments, and responses; and 2) for secondary purposes like evaluations, legal/research use, and assessing staffing/finances. Medical records must be complete and accurate to defend against malpractice suits and help determine insurance claims. The most widely used format is the problem-oriented veterinary medical record (POVMR), which commonly includes client information, history, exams, problem lists, notes, forms, and summaries.
Medico Legal implication of medical records-IndiaSrishti Bhardwaj
Medico legal liabilities related to patient records,
Medical Record committee and role of committee Hospital Utilization
Bed turnover ratio,
Average length of stay,
Death rate,
Bed occupancy rate
Unit 4- BVUCHMSR Portion (Sem-3)
Types of records and common record keeping forms & computerized documenta...Siva Nanda Reddy
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.
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.
The document discusses the planning and organization of a medical records department in a hospital. It begins by defining medical records and outlining their purposes for patients, doctors, hospitals, and research. It then describes how to plan and organize the department, including establishing sections for admissions, central records, and outpatient records. Staffing requirements are provided for a 500-bed hospital. Physical facility needs are also outlined. The document concludes by explaining the process of medical record flow upon patient admission.
This document outlines the goals and organization of a medical record management department. The key points are:
1) Medical records are essential for patient care, research, and healthcare planning. Accurate records are needed to evaluate care quality and access health status.
2) The goals of the medical records department are to maintain high quality records, generate health information, ensure care quality, protect privacy, and support various uses including research, policy, and legal/insurance needs.
3) The department is overseen by a Medical Records Officer and organizes registration, audits, forms, and work distribution to achieve effective records management.
How Can Hospitals Improve Their Patient Referral Management By Complying With...GaryRichards30
Meaningful use (MU) is a set of standards that defines criteria for electronic health records (EHR) and their effective use through activities like clinical data exchange between providers. The document discusses how hospitals can meet MU standards to qualify for incentive payments and avoid penalties by using patient referral management systems that integrate with their EHRs. Such integrated systems allow secure sharing of patient data, tracking of referral timelines and statuses, managing referral workflows, and analytics on referral patterns.
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.
A critical analysis of purchasing arrangements under BPJS in Indonesiaresyst
This document summarizes a presentation on strategic purchasing arrangements under Indonesia's National Health Insurance program (BPJS). It outlines the country's transition to universal health coverage through BPJS, describes the key actors and financing mechanisms, and identifies gaps and challenges, including unclear roles and accountability between BPJS and the Ministry of Health, limited data and monitoring capacity, problems with incentive structures, and inadequate resources and capacity at BPJS to effectively manage the program and monitor providers. Recommendations include strengthening collaboration between central and local governments, public reporting on performance, and reforming BPJS's management culture.
Introduction to Medical records and Documentation revised 01-13kbpennington
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.
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.
This document provides information on various pharmacy records and reports that must be maintained, including controlled substance inventory, medication orders, manufacturing records, purchase records, and workload records. It discusses the importance of accurate prescription filing records for both legal and patient care purposes. An example drug profile on Duloxetine is presented, outlining its description, indications, contraindications, warnings, dosage, and adverse effects. The document also discusses patient medication profiles and examples of drug interaction related to absorption, distribution, metabolism, and excretion.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
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.
Hospital Statistics and Pabon Lasso Model of Hospital Performance Measurement Zulfiquer Ahmed Amin
This document discusses key concepts and definitions related to hospital statistics. It defines key terms like data, information, statistics, hospital statistics, admission, discharge, bed occupancy rate, length of stay, and more. It also describes different types of hospital statistics reports including those related to beds, admissions, workload, and care evaluation. The uses and importance of collecting and analyzing hospital statistics are outlined.
Medical Record system: training to staff, maintenance & Retention & StorageSrishti Bhardwaj
Developing recording system in the hospital:
Maintaining adequate records on the patient file,
Training programs for staff,
*Retention and storing of medical Records*:
Outpatient,
Inpatient,
Medico legal cases retention policies,
process of medical record storing
The document discusses the health record system at the National Cancer Institute in Malaysia. It involves using electronic medical records (EMR) and the FiSiCien system to improve patient care. Patient records are stored securely using a Terminal Digit system and manual filing with pocket files. Records are retrieved upon request for purposes like insurance claims but charges apply. The system aims to complete records within 30 days and properly dispose of records after 7 years.
Courts are rapidly becoming a gold mine of information for private companies that re-sell case information for such purposes as credit, criminal record, and rental history checks. This session will address issues surrounding the use of court information for public purposes, including what information should be available to non-parties, who is responsible for ensuring its accuracy, whether courts should charge for access and on what basis, and how long information should be available?
Develop, Test and Deploy your SOA Application through a Single PlatformWSO2
WSO2 Carbon Studio is a development tool that allows users to develop, test, and deploy SOA applications on the WSO2 Carbon platform through a single integrated environment. The Carbon platform provides capabilities like service hosting, message mediation, data access, security, and process orchestration. Carbon Studio supports developing various service types, mediation configurations, data services, registry resources, and business processes. It allows deploying applications to local and remote Carbon servers for debugging and testing purposes. Carbon Studio aims to provide a one stop solution for the entire SOA application lifecycle.
Reference Sources: Origin, Evaluation and UsePrince Raja
This document discusses reference sources, including their definition, categorization, history, and evaluation. It provides details on the different types of reference sources such as indexes, bibliographies, dictionaries, and encyclopedias. The document also covers the development and arrangement of reference collections in libraries. While reference sources are increasingly available in electronic formats, the document argues that the ability to evaluate content and differentiate between source types will remain important skills for reference librarians.
The document summarizes an agenda for a webinar on Records Management in Alfresco. The webinar will include an overview of records management concepts and the Alfresco records management module, a demonstration of the module, and a question and answer session. Key topics to be covered are the records management content model, file plans, records, and user interfaces for searching and reporting on records.
The document discusses an introductory session on records and information management, defining what records and non-records are, the importance of metadata, and providing an overview of electronic records and the challenges of managing them. It covers topics like the records lifecycle, definitions of records and their characteristics, and differences between paper and electronic records.
This document provides an overview of different types of information sources for research, including periodicals like magazines, scholarly journals, trade journals and newspapers. It also discusses reference sources like encyclopedias, dictionaries, biographical sources, geographical sources, directories, almanacs, handbooks and government documents. Additionally, it covers the differences between primary and secondary sources, and when different information source formats are most appropriate to use.
Part 1 of a Training Course on Establishing An Institutional Records Management and Archival Collection Development Program for RVM Schools (held at the RVM Regional House, Singalong, Paco, Manila on 2002 Dec. 11-2 , at the RVM Regional House, Cebu on 2003 Jan. 24-25, at the RVM Regional House, Davao City on 2003 Feb. 28-March 1, and at the RVM Regional House, Cagayan de Oro City. on 2003 March 7-8
Two Factor Authentication Based Locker SystemIRJET Journal
This study evaluated the completeness of documentation in 268 medical records from four wards of a hospital from January to March 2022. The records were assessed on six types of forms, with incomplete documentation defined as less than half of entries filled out. Results showed the physician notes regarding patient status had the highest rate of incomplete documentation (87.7%), followed by the clinical pharmaceutical sheet (86.19%). The nursing sheet had the lowest rate of incomplete documentation (53.7%). The study concludes the documentation in patient records, especially physician notes and the clinical pharmaceutical sheet, was clearly inadequate. It recommends a quality improvement project and periodic assessments to boost medical record documentation completion.
Evaluation of the medical records documentation completenessIRJET Journal
This study evaluated the completeness of documentation in 268 medical records from four wards of a hospital from January to March 2022. The records were assessed on six types of forms. Overall, documentation was most incomplete for progress/physician notes (87.7% incomplete) and clinical pharmaceutical sheets (86.19% incomplete), which document patient status and treatment details. Nursing sheets had the most complete documentation (53.7% incomplete). The study concludes the medical record documentation in general is inadequately completed, especially for notes and treatment sheets. It recommends hospital quality improvement projects and periodic assessments to boost documentation.
The Patient Record: Hospital, Physician Office, and Alternate Care Settings
Reference: Michelle Green and Mary Jo BOWIE
At the end of this chapter,
the student should be able to:
Differentiate among various types of patient records
Summarize the purpose of the patient record
Provide examples of administrative and clinical data
Delineate provider documentation responsibilities
Summarize the development of the patient record
Explain the correct method for correcting documentation
Distinguish between manual and automated record formats
Discuss the importance of authentication of records
Compare alternative storage methods
Summarize patient record completion responsibilities
Patient Registries: A New Pillar of Modern CareQ-Centrix
www.q-centrix.com
A vital resource for patient data are registries. This white paper examines the rise of patient registries, how hospitals are taking advantage of the data, the challenges hospitals face in submitting quality information, and the benefits of real-time registry reporting.
Relationships of Providers’ Accountability of Nursing Documentations in the C...IJEAB
Documentation demonstrates the unique contribution of nursing to the care of clients. This study investigated the relationships of Providers accountability of nursing documentations in the clinical settings. Judgmental and simple random sampling techniques were used to select documented nursing actions for 264 clients. One research question and four null hypotheses guided the study. The instrument used for data collection was checklist on Nursing documentation in the clinical setting. Descriptive statistics of frequency, means and standard deviation (SD) were used to summarize the variables. Pearson Product Moment correlation was used to answer the research question, while analyses of variance (ANOVA) was adopted in testing the null hypotheses at 0.05 level of significance. The result indicated that significant correlation existed between legal implications of nursing documentation and the core principles of nursing documentation. Significant differences were also observed among providers’ accountability of nursing documentations with regard to promotion of interdisciplinary communication, legal implications of documentation, impacts on quality assurance and nursing science.
The document summarizes the use of electronic health records (EHRs) for syndromic surveillance, using the example of Zika virus. It discusses how EHRs can help improve reporting of outbreaks by recording patient information. While EHRs provide advantages like improved reporting efficiency and criterion validity of data, they also have limitations like the need for diagnostic and demographic accuracy. The document reviews literature on different surveillance systems and their use in various healthcare settings. It concludes by discussing opportunities for further research, such as including new diseases in surveillance systems and improving collaboration between public and private health sectors.
Medical audit helps determine the quality of care provided to patients. It involves systematically reviewing clinical records and hospital services against standards to identify areas for improvement. The summary analyzes key aspects of conducting a medical audit, including defining standards and criteria, collecting data, measuring performance, identifying changes, and sustaining improvements over time through re-auditing. Medical audits aim to enhance patient care and outcomes.
International Journal for Quality in Health Care 2003; Volume .docxnormanibarber20063
This document discusses clinical indicators that can be used to measure health care quality. It defines clinical indicators as measures that assess health care processes or outcomes. Indicators can be rate-based, providing quantitative measures over time, or sentinel, identifying undesirable individual events. Indicators can relate to the structure, process, or outcome of care. Structure indicators assess resources, process indicators assess the care provided, and outcome indicators assess the effects of care. Risk adjustment is important when comparing outcomes to account for factors outside of health care. Choosing indicators requires considering the strength of evidence linking the indicator to outcomes.
A complete medical record will have a patient information form, medical history, physical examination, consent form, nursing records, doctor’s orders and progress reports, and more.
Knowledge and Practice of Documentation among Nurses in Ahmadu Bello Universi...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Role of Medical Transcription for PatientsNancy Hall
Uncover the significance of medical transcription in enhancing patient care through accurate and accessible medical documentation.
Visit us- https://www.tridindia.com/transcription/medical-transcription-services/
EHR and HIS systems can improve patient care in several ways:
1. EHR decreases wait times, improves safety by tracking medications and medical history, and allows easy sharing of records between providers.
2. HIS streamlines processes across hospitals and providers, reducing costs. It provides centralized access and management of patient medical records and appointments.
3. Both systems increase productivity and quality of care by giving providers fast access to patient information.
EHR and HIS systems can improve patient care in several ways:
1. EHR decreases wait times, improves safety by tracking medications and medical history, and allows easy sharing of records between providers.
2. HIS streamlines processes across hospitals and providers, reducing costs. It provides centralized access and management of patient medical records and appointments.
3. Both systems increase productivity and quality of care by giving providers fast access to patient information.
Why Electronic Health Records are Ill Suited for Population Health 012616infomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform functions like enrollment tracking, provider networking, utilization review, claims processing, and quality reporting that are beyond the scope of most EHRs. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems designed for the specific demands of population health management.
Why Electronic Health Records are Ill Suited for Population Healthinfomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform tasks like enrollment tracking, provider networking, utilization review, and claims adjudication across different clinical systems. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems with greater functionality for care coordination, quality monitoring, and financial reporting at a population level.
Challenges of the Healthcare Industry in Indiadrparul6375
he healthcare industry in India faces several challenges, ranging from infrastructure and access to healthcare services to regulatory issues and affordability. Some of the key challenges include:
Infrastructure and Resource Constraints: India's healthcare infrastructure is often inadequate, especially in rural areas. There is a shortage of hospitals, clinics, beds, medical professionals, and essential medical equipment. This imbalance between demand and supply leads to overcrowding in healthcare facilities and compromises the quality of care.
Accessibility and Geographic Disparities: Accessibility to healthcare services varies significantly across different regions of India. Rural areas often lack basic healthcare facilities, forcing people to travel long distances for treatment. This geographic disparity exacerbates healthcare inequalities, with urban populations having better access to healthcare compared to rural populations.
Affordability and Financial Barriers: Healthcare costs in India can be prohibitively expensive for many people, particularly those from low-income backgrounds. Out-of-pocket expenditure on healthcare is high, pushing many families into poverty. Lack of comprehensive health insurance coverage further exacerbates financial barriers to accessing quality healthcare services.
This document reviews different models of clinical governance and their potential to improve quality in Australian primary health care. It summarizes a systematic review of the literature on clinical governance models. The review found that interventions at various levels can improve health care capabilities, but improvements depend on the type of care and how processes can be standardized. Models using targeted, peer-led feedback on individual clinician's practices showed the most evidence of improving quality. Top-down models driven only by external incentives or accreditation showed little to no quality improvements and in some cases reduced accessibility. For clinical governance to be effective in Australia it needs locally relevant indicators, use of clinical software, support from regional organizations, and learning from models in Aboriginal community controlled healthcare.
In the growth of scientific medicine, Medical Records (now called, Health Information) have played an important role as a tool and basis for planning patient care besides Medical Education, Research and Legal protection. Manual Medical Records have undergone tremendous transformations as the healthcare policy makers and healthcare providers have realized that good healthcare could be possible only when scientific, comprehensive and integrated Medical Records are maintained from birth to death including birth information, immunizations, child growth and periodic health problems and remedies provided.
introduction to medical record management , functions, objectives, and importance of record keeping to patient, doctors and hospitals. easy explanation about record management
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≲
1
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truly diverge from their low-
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Medical Record Audit in Clinical Nursing Units in Tertiary Hospital
1. IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 4, Issue 6 Ver. I (Nov. - Dec. 2015), PP 27-33
www.iosrjournals.org
DOI: 10.9790/1959-04612733 www.iosrjournals.org 27 | Page
Medical Record Audit in Clinical Nursing Units in Tertiary
Hospital
1
Olfat A. Salem, 2
Hazel N. Villagracia, 3
Matarah A. Dignah,
BSN, RN, MSN, PhD; BSN, RN, MAN, EdD, BSN, RN
1.
Nursing Administration and Education Department, College of Nursing - King Saudi University, Kingdom of
Saudi Arabia andNursing Administration Department, Faculty of Nursing, Menoufia University Egypt
2
Nursing Administration and Education Department, College of Nursing - King Saudi University, Kingdom of
Saudi Arabia
3-
Master Student, Medical Surgical Department, College of Nursing, King Saudi University
Abstract: Auditing the Medical Record is maintained by ‘proper management of health records and accurate,
comprehensive record-keeping. Ensuring quality of patient care documentation can be attainted through its
completeness in its medical record. This parameter is essential in the continuity of care rendered by
different health professionals in the hospital. In return, the medical records can promote safety and effective
communication with the health care team.
Purpose: This research was conducted in a government tertiary hospital in Riyadh which caters Maternity and
Child Care services. The estimated bed capacity of this hospital is 500. This study evaluated the
completenessof the content of medical record utilizing the Patient Medical Record Content ( PMRC ) Standards
of the hospital.
Method: Quantitative descriptive research design was used in conducting this study. The data has been
collected from four (4) clinical unitsnamely, gynecological, post-partum, pediatric, and antenatal units in a
selected government tertiary hospital with 310 beds specializing in maternity and pediatric care, A purposive
sampling with 10% set criterion has been used to reach the target medical records for auditing. The tool that
was used in auditing the medical record is PMRC Standards of the hospital. The study was conducted between
December 2014 and January 2015. Data were analyzed using the Statistical Package for Social Sciences (
SPSS ) windows, version 16.
Result: Each clinical unit was evaluated using PMRC Standards Tool of the hospital. In the four (4) units, the
total number of medical records audited were as follows: Gynecological Unit ( n= 3 ); Post-Partum ( n= 14 );
Pediatric ( n= 6 ); Ante-natal ( n= 5 ). Twenty eight ( n= 28 ) medical records have shown that they have
almost all complete content except from items like: Protocol Order, Braden Scale, Patients’ Bill of Rights
Forms. In items that were incomplete, the following forms were noted: Echo Reports, Radiology, Social
Worker, Fall Assessment and Re-assessment, Nursing Care Plan, ER Assessment Sheet, Medication Record,
Therapeutic Nutrition forms, Nurses’ Progress Notes, History and Physical Examination, Nursing Admission
Assessment, ER Nursing Assessment Sheet, Pain Management , Patient Family Health Education.
Conclusion: In this study, there were missing or incomplete important items in the medical record.
Prioritizing medical records in terms of its completeness and maintaining compliance to standards can help a
hospital promote safety , better collaboration and proper communication. The use of data in the medical
record will lead to quality , effective nursing and medical care. In future studies, it is recommended that other
criteria not only completeness can be used in evaluating medical records.
Keywords: Medical Record , Audit, Clinical Nursing Units
I. Introduction
In 1995 , the Audit Commission maintained that „proper management of health records and accurate,
comprehensive record-keeping are essential to effective patient care and continuity of care between different
health professionals‟.This assertion was made as part of a wide-ranging report on hospital health records, (1).In
1999, there was an improved standards of keeping records with a percentage of 8% for four years, (2).As per
the Joint Commission on the Accreditation of Healthcare Organizations, it should contain the following
components: reason for hospitalization, significant findings, procedures and treatment provided, patient‟s
discharge condition, patient and family instructions (as appropriate), and attending physician‟s signature,(3).A
medical record is a systematic documentation of a patient‟s medical history and care which is compiled and
stored by the health care providers, (4). A Medical Record Audit is a type of quality assurance task which
involves formal reviews and assessments of medical records to identify where a medical organization stands in
relation to compliance and standards. A medical record audit was not really a big deal several years back,(5).
Clinical documentation was originally meant for providers or physicians to access important patient details to
2. Medical Record Audit in Clinical Nursing Units in Tertiary Hospital
DOI: 10.9790/1959-04612733 www.iosrjournals.org 28 | Page
identify medical solutions. With the minimal possibility for medical records to serve as legal records, medical
record audit requirements did not play the crucial roles back then. Insurance companies did not require medical
institutions to present documents to support the claims and charges being reported in accordance to the services
delivered, as physicians had taken care of records, (6).
A well planned evaluation of medical records and the related clinical documentation practices allows
hospitals and physicians to have an accurate view of their current standings with regard to accuracy and
compliance for medical record keeping. The law requires that all actions related to medical services be recorded
completely and accurately. A record should be generated whenever a health care service is involved and this
includes all tests, diagnosis, treatments, and nursing care. While accurate clinical documentation is beneficial,
failure to meet the legal requirements for medical records may lead to different types of risks. As these records
affect the lives of individuals, each detail indicated in a certain health document must be based on facts and
professional actions,(7). There are two ways by which Medical Record Audit can be done, one in terms of
people performing audit and the other in terms of action taken, (8). The Records Standards Programme refers to
developing a programon medical records that will identify the need, review the literature and establish a major
stream of work. The aim of the RCP HIU (Royal College of Physicians , Health Informatics Unit‟s ) , Records
Standards programme is to improve the quality of clinical information in the hospital setting by: first,
developing standards for recording and communicating information about patients; second, applying these
standards to medical records to improve the validity and utility of patient data; and third, structure the records
so that the information can be incorporated into electronic records, shared with other healthcare providers and
analyzed for performance monitoring with confidence, (9).
The goal of a quality assessment program for healthcare documentation is to ensure that patient care
documentation is clear, consistent, accurate, complete, and timely, and that it satisfies stated or implied
requirements for documentation of patient care, (10).Medical records serve as documented proof in case any
legal issues regarding quality of treatment ornegligence arise. These records form reliable and easily accessible
data sources for health policy planning, (11).Medical records serve a number of important functions such as : “
as an archive of important patient medical information for use by other health care providers and patients ; a
source of data to assess performance in practice such as treatment of specific chronic medical conditions (e.g.,
diabetes), postoperative care, or preventive services; and the documentation of clinical decisions. One can
readily see how these patient care functionsofthe medical record can be used for educational and evaluative
purposes , (12).Understanding the basics of the audit process is crucial to maximizing the utility of medical
records as a tool for both formative and summative assessment. Because medical record audits can be time-
consuming, one should not perform an audit until clear about the educational and evaluation purpose of the
audit. The audit cycle is closely related to the PDSA (plan-do-study act) quality improvement cycle, (13).
Health care records promote patient safety, continuity of care across time and care settings, and support
the transfer of information when the care of a patient/client is transferred e.g.at clinical handover, during
escalation of care for a deteriorating patient and transfer of a patient / client between settings, (14).The main
purpose of a health care record is to provide a means of communication to facilitate the safe care and treatment
of a patient / client. A health care record is the primary repository of information including medical and
therapeutic treatment and intervention for the health and well-being of the patient / client during an episode of
care and informs care in future episodes. The health care record is a documented account of a patient / client‟s
history of illness; health care plan/s; health investigationand evaluation; diagnosis; care; treatment; progress and
health outcome for each health service intervention or interaction. The health care record may also be used for
communication with externalhealth care providers, and statutory and regulatory bodies, in addition to facilitating
patient safety improvements; investigation of complaints; planning; audit activities; research (subject to ethics
committee approval, as required); education; financial reimbursement and public health , (15).
Auditing the Medical Record is maintained by proper management of health records and accurate,
comprehensive record-keeping. Ensuring quality of patient care documentation can be attainted through its
completeness in its medical record. This parameter is essential in the continuity of care rendered by different
health professionals in the hospital. In return, the medical records can promote safety and effective
communication with the health care team. The purpose of this study was to evaluate the completeness of the
content of medical record utilizing the Patient Medical Record Content (PMRC) Standards in a selected
government hospital in Riyadh. This study is significant in evaluating the completeness of the content set
according to the standards of the hospital.
II. Objective.
To evaluate the completeness of the medical record utilizing the PMRC standards in a selected
government hospital in Riyadh. Differences in the completeness in the four (4) clinical units were determined.
3. Medical Record Audit in Clinical Nursing Units in Tertiary Hospital
DOI: 10.9790/1959-04612733 www.iosrjournals.org 29 | Page
III. Method.
Quantitativedescriptive design was used in this study. The investigators conducted the study in a
selected tertiary government hospital in Riyadh which caters Maternity and Child Care services. The estimated
bed capacity of this hospital is 310. This study evaluated the completeness of the content of medical record
utilizing the Patient Medical Record Content ( PMRC ) Standards of the hospital. Administrative permissions
were sought from the College of Nursing to the selected hospital as the locale of the study. The units with
medical patient records were selected by purposive sampling technique. The instrument used for collection of
data was the PMRC of the hospital applied in four (4) clinical units. Preparation ofthe medical file content,
number of clinical units, number of beds in each clinical unit was done taking 1-2 days to collect the data. The
audit includes 10% of medical files for every clinical unit. In the four (4) unit selection, these records were
included in the monthof December, 2014 until January, 2015. Simple random probability sampling utilized for
the study. The sample size was 28 in the four (4) clinical units such as pediatric ward, antenatal care ward,
gynecology ward, postpartum care ward. Primary data for the audit was collected for the completeness of all
medical patient record content. A Checklist was prepared and utilizedcoding system such as “yes‟ for
compliance and “no‟ for non-compliance to evaluate completeness using the PMRC standards of the hospital.
Data were analyzed using descriptivestatistics of the SPSS version 16.
IV. Results and Discussion
Table 1 shows the distribution of medical record audited by the investigators in relation to bed
capacity.
Table 1. Distribution of Medical Records Audited according to Bed Capacity
Clinical Units Total Bed Capacity (TBC) 10% of TBC
Gynecology 25 3
Post-partum 138 14
Antenatal 50 5
Pediatric 62 6
Total Medical Records
Audited
275 28
Logan, Gorman, Middleton explored the attributes of quality in recorded clinical encounter data,
examines issues in measuring these attributes, and describes a method for measuring two attributes,
completeness and correctness (16). In this study, there are four (4) clinical units that have been examined for
completeness of all medical records.
Each unit was evaluated using PMRC Standards of the hospital. In the four (4) clinical units, the
total number of medical records audited were as follows: Gynecological Unit ( n= 3 ); Post-Partum ( n= 14 );
Pediatric ( n= 6 ); Ante-natal ( n= 5 ). Twenty eight ( n= 28 ) medical records have shown that they have
almost all complete content except from items like: Protocol Order, Braden Scale, Patients‟ Bill of Rights
Forms. In items that were incomplete, the following forms were noted: Echo Reports, Radiology, Social
Worker, Fall Assessment and Re-assessment, Nursing Care Plan, ER Assessment Sheet, Medication Record,
Therapeutic Nutrition forms, Nurses‟ Progress Notes, History and Physical Examination, Nursing Admission
Assessment, ER Nursing Assessment Sheet, Pain Management , Patient Family Health Education. According
to Reiser, health records document the pertinent facts of a patient's life and health history, including past and
present illness(es) and treatment(s), written down by the health professionals handling the patient's care. (Table
1).
The records must be compiled in a timely manner and contain sufficient data to identify the patient,
support the diagnosis or reasons for the healthcare encounter, justify the treatment, and accurately document the
results, (17). Good quality healthcare data play a vital role in the planning, development, and maintenance of
healthcare services. Quality health records are essential for the maintenance of optimal healthcare, ( 20 ).
4. Medical Record Audit in Clinical Nursing Units in Tertiary Hospital
DOI: 10.9790/1959-04612733 www.iosrjournals.org 30 | Page
Table 2. Summary Distribution of Completeness of Medical Records According to PMRC Standards in
the Four (4) Clinical Units
Content Gyne PP Ante Pedia
F % f % F % F % Total
Admission 15 83.3% 71 84.5% 23 76.6% 27 75% 79.85% (1)
Graphic 6 25% 65 58% 13 32.5% 14 29.1% 36.15% (5)
Medication 5 27.7% 31 36.9% 10 33.3% 7 19.4% 29.33% (6)
Physician‟s
Notes
17 62.9% 92 73.0% 20 44.4% 32 59% 59.83% (2)
Nurses‟ Notes 17 56.6% 79 56.4% 28 56% 28 46.6% 53.9% (3)
Operating
Room
0 0 20 35.7% 6 3% 0 0 9.68% (8)
Diagnostic 4 19.0% 49 5% 14 4% 8 19% 11.75%(7)
Miscellaneous 11 45.8% 60 53.5% 23 57% 18 37.5% 48.45% (4)
Total 75 40.04%
(2)
467 50.38% (1) 137 38.35%
(3)
134 35.7%
(4)
41.12%
According to the PMRC Standards, in terms of completeness, Admission Sheets are ranked number 1 (
79.85%). Second to Admission Sheets, are the Physician‟s Notes (59.83% ), third are the Nurses‟ Notes (
53.9% ); fourth are the Miscellaneous forms ( 48.45% ); fifth are the Graphic forms ( 36.15% ); sixth are the
Medication sheets ( 29.33% ); seventh are the Diagnostic Sheets ( 11.75% ); and the least ( eight in rank ) are
the Operating Room sheets ( 9.68 % ). Almost all complete in the Gynecological, Post partum , Antenatal and
Pediatric Units are the Admission Sheets ( 83.3%, 84.5%, 76.6%, and 75.0% respectively ), and the least are
the Diagnostic Forms ( 19.0% 5.0%, 4.0% and 19.0% , respectively). The most complete unit is the Post
partum( 50.38% ) , followed by Gynecological ( 40.04% ), Antenatal ( 38.35% ) and Pediatric ( 35.7% ).(Table
2).
Supporting the results of the study is coming from where patient health record review has improved
the chart documentation of care by medical house officers and has impacted on the quality of health record
documentation, ( 21 ), where Admission Sheets are all almost complete because of screening in this hospital in
terms of their admission. Physicians in the study of Tang, who used a computer-based patient record (CPR)
produced more complete documentation and documented more appropriate clinical decisions, as judged by an
expert review panel. Because the physicians who used the CPR in this study volunteered to do so, further study
is warranted to test whether the same conclusions would apply to all CPR users and whether the improvement in
documentation leads to better clinical outcomes,(25). Similar findings were seen in the abstracted records
coming from the departments of obstetrics and gynecology (336, 45.90%), pediatrics (178, 24.32%), accident
and emergency (14.0%, 19.13%), medicine (38, 5.19%), surgery (30, 4.09%), and psychiatry (10, 1.37%). These
percentages reflected the following hospital discharge patterns given in the hospital statistics for 2008, ( 26). A
periodic hospital-wide comprehensive review of patients' health records supports the clinical documentation
improvement program,(27 ).
In this study, from the four (4) clinical units, it shows that the most complete is the Post-partum unit
and the least is the Pediatricunit. It is often said that an adequate health record indicates adequate care, and
conversely, a poor health record indicates poor care. Indeed, a patient who received poor care can have a
complete and thorough record, but the reverse is more likely to be true, that is, a patient may have received
adequate care which is poorly documented.Huffmann, stressed that health records document the pertinent facts
of a patient's life and health history, including past and present illness(es) and treatment(s), written down by the
health professionals handling the patient's care. The records must be compiled in a timely manner and contain
sufficient data to identify the patient, support the diagnosis or reasons for the healthcare encounter, justify the
treatment, and accurately document the results, (17).
The medical record has been used for more than a century as a tool to assist clinicians in the care of
patients. Today, the medical record has a comprehensive purpose: “to recall observations, to inform others, to
instruct students, to gain knowledge, to monitor performance, and to justify interventions, (18 ).The quality of
health records depends on the health information recorded by the healthcare professionals authorized to provide
and document such care. The term „data quality‟ refers to the characteristics and attributes of the data,
specifically: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, (detail
contained), precision, relevancy, and timeliness. Problems with data quality make the health record linkage
process cumbersome, unreliable, and of little value to organizations, providers, and patients,(19), but this study
reflected only its completeness as the major criterion in the audit, as shown in Table 1, and found to be a
limitation.
Most importantly, senior members of health information departments must ensure adequate
documentation collection, analysis, and assessment in order to guarantee the completeness, availability, and
5. Medical Record Audit in Clinical Nursing Units in Tertiary Hospital
DOI: 10.9790/1959-04612733 www.iosrjournals.org 31 | Page
accessibility of health records, (20).Improving the quality of healthcare data in patient health records can affect
clinical and administrative decision making in many ways, (22)and impact on health economics, increase patient
safety, provide evidence to support clinical decision making through healthcare research, and improve the
information provided to patients on their illness and care, and the effectiveness of clinical care pathways, (23).
Similar to the findings of this study , is the subsequent documented limitations of the current record-
keeping system. Several investigators have quantified the problem of data missing from the record itself, (24).
To investigate whether using a computer-based patient record (CPR) affects the completeness of documentation
and appropriateness of documented clinical decisions. Completeness of problem and medication lists in
progress notes, allergies noted in the entire record, consideration of relevant patient factors in the progress note's
diagnostic and treatment plans, and appropriateness of documented clinical decisions were seen in the study of
Tang, ( 25 ).In the study of So, where the poorly and well-documented charts were compared by patient,
physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of
the 2,061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented
varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics.
The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but
varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid
administrative data, which reduces the communication of clinical information among healthcare providers, (28).
Also, hospital discharge summaries serve as the primary documents communicating a patient‟s care plan to the
post-hospital care team.( 30, cited in 29 ).On the one hand,a recent systematic review noted that studies that
have examined recommended discharge summary components more specific than those mandated by the Joint
Commission have found relatively high rates of omission, ( 30 , 31,32 cited in 29).The discharge summaries
analyzed were seen to be inadequate especially in documenting course during the hospital stay, condition at
discharge, appropriate instructions and the treating physician‟s details. These can probably be addressed by
introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and
doctors should be trained to write legible, complete discharge summaries,(39).
The Joint Commission mandates that six components be present in all U.S. hospital discharge
summaries. Despite the critical importance of discharge summaries in care transitions and patient safety, no
studies have examined how well discharge summaries adhere to Joint Commission standards. In the study of
Kind, Joint Commission-mandated discharge summary components were specifically defined and abstracted
from discharge summaries for all hip fracture, stroke, and cancer patients discharged directly to subacute care
facilities from a large Midwestern academic hospital between 2003 and 2005 (N = 599), preliminary results
show that most (88–100 percent) discharge summaries included five of the six Joint Commission components.
The remaining component, “patient‟s discharge condition,” was included the least often (79–90 percent). The
discharge summaries adhere well to Joint Commission discharge summary component standards. However,
given the discharge summary‟s pivotal communication role in care transitions, even a small frequency of
omitted patient discharge condition information is a concern and may affect patient safety, (29).
The high rate of adherence to completeness in this study is better as shown in a high percentage of
consistency from the four (4) clinical units. In the study of Kripalani, standards for discharge summaries within
this study sample is likely due to two major factors. First, the Joint Commission-mandated components are
extremely broad/general. With minimal documentation, it is simple for a practitioner to meet the Joint
Commission component standards. A recent systematic review noted that studies that have examined
recommended discharge summary components more specific than those mandated by the Joint Commission
have found relatively high rates of omission, (30).While in the study of Diver andCraig, they worked in a busy
regional fracture unit, where it was noted that important data was being omitted from medical notes. In an
attempt to improve on this, an admission proforma was formulated. This was designed to be easily and quickly
completed. Notes were audited on two separate weeks, the first before, and the second after introduction of the
proforma. The overall results demonstrate statistically significant improvements in documentation with a
proforma, and concur with the limited previous literature in this area, (33).
Medical records serve many functions but their primary purpose is to support patient care. The RCP
Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in
England and Wales. There is currently a major drive to computerise medical records across the NHS, but
without improvement in the quality of paper records the full benefits of computerisation are unlikely to be
realised. The onus for improving records lies with individual health professionals. Mann and Williams stressed
that structuring the record can bring direct benefits to patients by improving patient outcomes and doctors'
performance. The Health Informatics Unit (HIU) has reviewed the literature and is developing evidence-based
standards for record keeping including the structure of the record. The first draft of these standards has been
released for consultation purposes. This article is the first of a series that will describe the standards, and the
evidence behind them.(34)
6. Medical Record Audit in Clinical Nursing Units in Tertiary Hospital
DOI: 10.9790/1959-04612733 www.iosrjournals.org 32 | Page
Batham stressed the importance of medical of medical care that is provided by dedicated but often
inexperienced young doctors, nurses and medics. This audit looks at the quality of medical records that are
available to these deployed clinicians and the quality of their record keeping against nationally set guidance for
the Summary Care Record (SCR) and Out of Hours record keeping, (35).A high standard of medical record
keeping is important for safe patient care and provides information for research, audit and medicolegal purposes.
Standards exist on what entries should contain, but as far as we are aware these standards are not regularly used
in South Africa. We compared surgical case notes at Prince Mishyeni Hospital with guidelines from the Royal
College of Surgeons of England,(36).Similar to the results of the study, the charts in the four clinical units serve
a lot of purposes especially if undergoing audit. Chart audits can serve many purposes, from compliance to
research to administrative to clinical. Virtually in any aspect of care that is ordinarily documented in the medical
record, chart audit can be done. Practices frustrated with clinical processes that don't work well can use chart
audits to document that something is wrong, find the defect in the process and fix it. Chart audits are often used
as part of a quality improvement initiative, (37). Healthcare professionals need to be aware of, and comply
with, standards. House officers should be given information about standards at departmental induction or during
medical training, (38).
V. Limitations of the Study
Limitations of the study have been seen as for variables such as In-Patient Medical Records; the time to
collect the data, the general content to the entire department without elaboration of details, removal of chart
content related to the clinical unit such as special papers concerning women, pregnancy and papers pertaining to
children, and attachments of the format content in the chart files.
VI. Conclusion:
On the basis of the findings of the study, there were missing or incomplete important forms/ sheets in
the medical record. Prioritizing medical records in terms of its completeness and maintaining compliance to
standards can help a hospital promote safety and better collaboration. Proper communication in the use of data
in the medical record will lead to quality and effective nursing and medical care. In future studies, it is
recommended that other criteria not only completeness can be used in evaluating medical records.
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