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Patient record system
The document discusses patient record systems, including their definition, principles, value, purpose, importance, and classifications. It covers paper-based and electronic documentation systems. Paper-based systems can use source-oriented, problem-oriented, or graphic methods. Electronic systems include electronic medical records, electronic health records, and computerized patient records. The objectives of patient record systems are to review patient care, provide an archival record, support research, and facilitate administration and auditing. Both paper-based and electronic systems aim to properly document a patient's condition and care over time.
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Patient record system
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- 2. DEFINITION • IT ISA PERMANENT WRITTEN COMMUNICATION THAT DOCUMENTS INFORMATION RELEVANT TO THE HEALTH CARE MANAGEMENT
- 3. PRINCIPLES • MINIMUM RECORDS •REVIEW THE RECORDS PERIODICALLY • SIMPLE , USEFUL , LEGIBLE • CONFIDENTIAL
- 4. VALUE OF CLINICALRECORD •SCIENTIFIC AND LEGAL •EVIDENCE FOR PATIENT CARE MANAGEMENT •LEGAL PROTECTION
- 5. PURPOSE •PROVIDES INFORMATION ON DISEASECONDITION •DATA FOR PLANNING AND EVALUATION •PLAN FOR FUTURE •EVALUATION OF SERVICES •RESEARCH
- 6. IMPORTANCE •FOR INDIVIDUAL ANDFAMILY •FOR THE DOCTOR •FOR THE NURSE •FOR THE AUTHORITIES
- 11.
- 12. (PAPER BASED DOCUMENTATION)TYPE •PAPER BASED DOCUMENTATION SYSTEM SOURCE ORIENTED METHOD (EG.ADMISSION RECORD) PROBLEM ORIENTED METHOD (P.O.M.) (EG.LIST OF CLIENT PROBLEMS) COMPONENTS DATA BASE PROBLEM LIST PLAN OF CARE PROGRESS NOTES FORMAT SOAP/ IER , PIE , DAR CHARTING BY EXCEPTION(CBE) GRAPHIC SHEETS AND FLOW CHARTS VARIANCE CHARTING (EG,INCIDENT REPORTING )
- 13. ELECTRONIC DOCUMENTATION ELECTRONIC MEDICAL RECORDS(EMR’S) &ELECTRONIC HEALTH RECORD TYPES (ELECTRONIC MEDICAL RECORDS) • DEPARTMENTAL • INTERDEPARTMENTAL • HOSPITAL EMR
- 14. HOSPITAL EMR •INTER HOSPITALEMR (TWO MORE HOSPITAL) •ELECTRONIC PATIENT RECORD(EPR) (PARTICULAR HOPSITAL) •COMPUTERISED PATIENT RECORD(CPR) •ELECTRONIC HEALTH CARE RECORD(EHCR) (ALL HEALTH INFORMATIONS)
- 15. • COMPUTERISED MEDICALRECORD (SCANNED IMAGES OF PATIENT’S PAPER RECORDS.) • DIGITAL MEDICAL RECORD (WEB BASED RECORD CONTROLLED BY HOSPITAL) • CLINICAL DATA REPOSITORY(STORE,THAT HOLDS AND MANAGES CLINICAL DATA)
- 16. ELECTRONIC HEALTH RECORD •TYPES • THE AUTOMATED MEDICAL RECORD-(PAPER WITH SOME COMPUTER GENERATED DATAS) • THE COMPUTERIZED MEDICAL RECORD (CMR)(ELECTRONICALLY AVAILABLE) • ELECTRONIC MEDICAL RECORD (EMR)(CONNECTING PREVIOUS LEVEL DATAS TO PRESENT SITUATION) • ELECTRONIC PATIENT RECORD (EPR)(FROM MULTIPLE INSTITUTIONS) • ELECTRONIC HEALTH RECORD (EHCR)(ADDITIONAL INFORMATION TO EPR) • STRUCTURE TIME ORIENTED EHR’S (CHRONOLOGICAL ORDER) PROBLEM ORIENTED MEDICAL RECORD (POMR)
- 18. OBJECTIVES • REVIEW PATIENTCARE,TAKE APPROPRIATE DECISIONS • PROVIDE AN ARCHIVAL AND LEGALLY ACCEPTABLE METHOD • TO PROVIDE MATERIAL FOR RESEARCHERS • ACT AS A SOURCE OF INFORMATION FOR HEALTH ADMINISTRATION • FOR HOSPITAL AUDITING • CARRY OUT THINGS IN RIGHT POSSIBLE MANNER
- 21. VALUE OF NURSESCLINICAL RECORD •PROVIDE BASE LINE DATA FOR FURTHER PLAN OF ACTIONS •FOR DIAGNOSTIC AND TREATMENT •TO EVALUATE THE WORKLOAD •SCIENTIFIC AND RESEARCH PURPOSE •FOR LEGAL PURPOSE
- 24. OBJECTIVES OF REPORTING •PRESENTS FACTUAL INFORMATION FOR COMMUNICATION • RECORDS USING FOR FUTURE REFERENCE • PROVIDES NECESSARY INFORMATION TO ALL RELATED TOPICS • HELPFUL IN MEASURING PERFORMANCE • PROVIDES VALUABLE AND CONSTRUCTIVE SUGGESTION TO MANAGEMENT
- 34. JOURNAL CONTENT 1.HOW TOKEEP GOOD CLINICAL RECORDS JOURNAL OF EUROPEAN RESPIRATORY SOCIETY ALEXANDER MATHIOUDAKIS ETAL.. -NEED OF KEEPING GOOD RECORDS -ADVANTAGES OF KEEPING GOOD CLINICAL RECORDS AND THE DISADVANTAGES OF POOR CLINICAL RECORDS -BASIC DO’S AND DON’TS IN CLINICAL RECORD ENTRIES 2. DOCUMENTATION OF MEDICAL RECORDS IN HOSPITALS OF MAZANDARAN UNIVERSITY OF MEDICAL SCIENCES IN 2014 JOURNAL OF ACADEMY OF MEDICAL SCIENCES OF BOSNIA AND HERZEGOVINA • BENYAMIN MOHSENI SARAVI ETAL..