The Medical Record

Author : Committee on Improving the Patient Record,Institute of Medicine
Publisher : National Academies Press
Page : 257 pages
File Size : 55,6 Mb
Release : 1997-10-28
Category : Medical
ISBN : 9780309578851

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The Computer-Based Patient Record by Committee on Improving the Patient Record,Institute of Medicine Pdf

Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.

Author : Institute of Medicine,Board on Health Care Services,Committee on Data Standards for Patient Safety
Publisher : National Academies Press
Page : 36 pages
File Size : 46,5 Mb
Release : 2003-07-31
Category : Medical
ISBN : 9780309185431

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Key Capabilities of an Electronic Health Record System by Institute of Medicine,Board on Health Care Services,Committee on Data Standards for Patient Safety Pdf

Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.

Author : Agency for Healthcare Research and Quality/AHRQ
Publisher : Government Printing Office
Page : 396 pages
File Size : 45,6 Mb
Release : 2014-04-01
Category : Medical
ISBN : 9781587634338

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Registries for Evaluating Patient Outcomes by Agency for Healthcare Research and Quality/AHRQ Pdf

This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.

Author : Giovanni Rinaldi
Publisher : Springer
Page : 224 pages
File Size : 41,8 Mb
Release : 2017-03-18
Category : Medical
ISBN : 9783319286617

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New Perspectives in Medical Records by Giovanni Rinaldi Pdf

This book provides innovative practical suggestions regarding the production and management of medical records that are designed to address the inconsistencies and errors that have been highlighted especially in relation to national eHealth programs. Challenges and lessons that have emerged from the use of clinical information and the design of medical records are discussed, and principles underpinning the implementation of health IT are critically examined. New trends in the use of clinical data are explored in depth, with analysis of issues relating to integration and sharing of patient information, data visualization, big data analytics, and the requirements of modern electronic health records. The spirit pervading the book is one of co-production, in which the needs of practitioners are taken into account from the outset. Readers will learn the basic concepts of how clinical information emanating from the doctor–patient relationship can be effectively integrated with genetic and environmental data and analyzed by complex algorithms with the goal of improving medical decision making and patient care. The book, written by European experts and researchers, will be of interest to all stakeholders in the field, including doctors, technicians, and policy makers.

Author : Jerome H. Carter,American College of Physicians--American Society of Internal Medicine
Publisher : ACP Press
Page : 478 pages
File Size : 50,8 Mb
Release : 2001
Category : Medical Records Systems, Computerized
ISBN : 1930513011

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Electronic Medical Records by Jerome H. Carter,American College of Physicians--American Society of Internal Medicine Pdf

Clinical Infomation Systems are increasingly important in Medical Practice. This work is a two-part book detailing the importance, selection and implementation of information systems in the health care setting. Volume One discusses the technical, organizational, clinical and administrative issues pertaining to EMR implementation. Highlighted topics include: infrastructure of the electronic patient records for administrators and clinicians, understanding processes and outcomes, and preparing for an EMR. The second workbook is filled with sample charts and questions, guiding the reader through the actual EMR implementation process.

Author : GD Mogli
Publisher : Jaypee Brothers Medical Publishers
Page : 0 pages
File Size : 46,9 Mb
Release : 2017-02-27
Category : Medical
ISBN : 9385891820

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Medical Records by GD Mogli Pdf

Part 1: Traditional Medical Records Organization and Management Procedures Chapter 1: History of Medical Records Administration Chapter 2: Role of Medical Records in Health Care Delivery Chapter 3: General Medical Records Standards and Policies Chapter 4: Legal Aspects of Medical Records and Electronic Health Records (EHRs) Chapter 5: Medical Audit Chapter 6: ICD-10 Revision, ICD-10CM and ICD-10 PCS Revision Chapter 7: Hospital Information System Chapter 8: How to Economize Health Service Expenditure Chapter 9: Organization and Management of the Medical Record Department Chapter 10: Medical Record Procedures Part 2: Design and Development of Hospital Information System (HIS) for Software Production Chapter 11: Computerization of the Medical Records Chapter 12: Challenges of the Health Care Delivery in 21st Century Chapter 13: Domain for Designing the Hospital Information System (HIS) Software Chapter 14: Designing the Hospital Ward Nursing Administrative Activities Chapter 15: Blood Transfusion Service Chapter 16: Pediatric Center Chapter 17: Diabetic Center Chapter 18: Dialysis Center Chapter 19: Dental Clinic Chapter 20: IVF (In Vitro Fertilization) Clinic Chapter 21: Occupational Health and Safety Chapter 22: Biomedical Equipment Maintenance Part 3: Development and Implementation of Electronic Health Records (EHR) Chapter 23: Perspective of Information Technology (IT) in Hospital Information System Chapter 24: Challenges in Hospital IT and Networking Design Chapter 25: Tips for Evaluation of Electronic Health Record Software Chapter 26: Roadmap for Successful Implementaion of EHR Chapter 27: Amalgamation of Manual Record (MR) with Electronic Health Records (EHRs) Chapter 28: Health Record Manager (HRM) Revolves around Patient as a Good Leader Chapter 29: Modern Trends and Issues of Developing Countries in Maintaining Medical Records Chapter 30: Health Information Management (HIM) Professionals Endurance in 21st Century Chapter 31: Implementation of Personal Health Record (PHR) Bibliography Appendix

Author : Neil S. Skolnik
Publisher : Springer Science & Business Media
Page : 161 pages
File Size : 43,6 Mb
Release : 2010-10-20
Category : Medical
ISBN : 9781607616061

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Electronic Medical Records by Neil S. Skolnik Pdf

Physician adoption of electronic medical records (EMRs) has become a national priority. It is said that EMRs have the potential to greatly improve patient care, to provide the data needed for more effective population management and quality assurance of both an individual practice’s patients and well as patients of large health care systems, and the potential to create efficiencies that allow physicians to provide this improved care at a far lower cost than at present. There is currently a strong U.S. government push for physicians to adopt EMR technology, with the Obama administration emphasizing the use of EMRs as an important part of the future of health care and urging widespread adoption of this technology by 2014. This timely book for the primary care community offers a concise and easy to read guide for implementing an EMR system. Organized in six sections, this invaluable title details the general state of the EMR landscape, covering the government’s incentive program, promises and pitfalls of EMR technology, issues related to standardization and the range of EMR vendors from which a provider can choose. Importantly, chapter two provides a detailed and highly instructional account of the experiences that a range of primary care providers have had in implementing EMR systems. Chapter three discusses how to effectively choose an EMR system, while chapters four and five cover all of the vital pre-implementation and implementation issues in establishing an EMR system in the primary care environment. Finally, chapter six discusses how to optimize and maintain a new EMR system to achieve the full cost savings desired. Concise, direct, but above all honest in recognizing the challenges in choosing and implementing an electronic health record in primary care, Electronic Medical Records: A Practical Guide for Primary Care has been written with the busy primary care physician in mind.

Author : Pradeep K. Sinha,Gaur Sunder,Prashant Bendale,Manisha Mantri,Atreya Dande
Publisher : John Wiley & Sons
Page : 244 pages
File Size : 53,8 Mb
Release : 2012-11-27
Category : Computers
ISBN : 9781118479667

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Electronic Health Record by Pradeep K. Sinha,Gaur Sunder,Prashant Bendale,Manisha Mantri,Atreya Dande Pdf

Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics," which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications. Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved. This book on Electronic Health Record: Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others Provides assessment of existing standards Includes a glossary of frequently used terms in the area of EHR Contains numerous diagrams and illustrations to facilitate comprehension Discusses security and reliability of data

Author : Samiran Nundy,Atul Kakar,Zulfiqar A. Bhutta
Publisher : Springer Nature
Page : 475 pages
File Size : 50,8 Mb
Release : 2021-10-23
Category : Medical
ISBN : 9789811652486

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How to Practice Academic Medicine and Publish from Developing Countries? by Samiran Nundy,Atul Kakar,Zulfiqar A. Bhutta Pdf

This is an open access book. The book provides an overview of the state of research in developing countries – Africa, Latin America, and Asia (especially India) and why research and publications are important in these regions. It addresses budding but struggling academics in low and middle-income countries. It is written mainly by senior colleagues who have experienced and recognized the challenges with design, documentation, and publication of health research in the developing world. The book includes short chapters providing insight into planning research at the undergraduate or postgraduate level, issues related to research ethics, and conduct of clinical trials. It also serves as a guide towards establishing a research question and research methodology. It covers important concepts such as writing a paper, the submission process, dealing with rejection and revisions, and covers additional topics such as planning lectures and presentations. The book will be useful for graduates, postgraduates, teachers as well as physicians and practitioners all over the developing world who are interested in academic medicine and wish to do medical research.

Author : Inc Peter Pauper Press
Publisher : Peter Pauper Press
Page : 0 pages
File Size : 54,9 Mb
Release : 2013-08
Category : Electronic
ISBN : 1441313842

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My Child's Health Record by Inc Peter Pauper Press Pdf

From babys well visits through the first 18 years, record your childs immunizations, measurements & percentiles, illnesses, instructions from the doctor (& questions to remember to ask), and more in this simple, attractive, and sturdy health journal. With tips and reminders, this little tracker provides the perfect place to record clear and concise medical history necessary for school, camp, college, insurance, a change of doctors, and personal reference. Small and thin enough to fit in a purse and a file, with archival paper to last a lifetime. Measures 5-1/2" wide x 8" high. 56 pages. Hardcover with elastic band closure. Inside back cover pocket.

Author : Colleen Doherty Lauster,Sneha Baxi Srivastava
Publisher : Jones & Bartlett Publishers
Page : 359 pages
File Size : 50,9 Mb
Release : 2013-03-25
Category : Medical
ISBN : 9781449645113

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Fundamental Skills for Patient Care in Pharmacy Practice by Colleen Doherty Lauster,Sneha Baxi Srivastava Pdf

Fundamental Skills for Patient Care in Pharmacy Practice enables students and new pharmacists to master the skills associated with clinical care in either the inpatient or outpatient setting. In accessible steps, this valuable resource provides the tools for gaining medication histories from patients and counseling them on the most effective and safe manner to take medications. Each chapter explores the background and practice of a critical skill, tools that aid in its development and mastery, and tips for success. Students and pharmacists will come away with the knowledge to identify drug-related problems and formulate plans for solutions to these problems. Fundamental Skills for Patient Care in Pharmacy Practice prepares future pharmacists to communicate effectively in verbal and written formats with health professionals and special patient populations as they prepare and present SOAP notes, patient cases, and discharge counseling.

Author : Hercules Dalianis
Publisher : Springer
Page : 192 pages
File Size : 49,8 Mb
Release : 2018-05-14
Category : Computers
ISBN : 9783319785035

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Clinical Text Mining by Hercules Dalianis Pdf

This open access book describes the results of natural language processing and machine learning methods applied to clinical text from electronic patient records. It is divided into twelve chapters. Chapters 1-4 discuss the history and background of the original paper-based patient records, their purpose, and how they are written and structured. These initial chapters do not require any technical or medical background knowledge. The remaining eight chapters are more technical in nature and describe various medical classifications and terminologies such as ICD diagnosis codes, SNOMED CT, MeSH, UMLS, and ATC. Chapters 5-10 cover basic tools for natural language processing and information retrieval, and how to apply them to clinical text. The difference between rule-based and machine learning-based methods, as well as between supervised and unsupervised machine learning methods, are also explained. Next, ethical concerns regarding the use of sensitive patient records for research purposes are discussed, including methods for de-identifying electronic patient records and safely storing patient records. The book’s closing chapters present a number of applications in clinical text mining and summarise the lessons learned from the previous chapters. The book provides a comprehensive overview of technical issues arising in clinical text mining, and offers a valuable guide for advanced students in health informatics, computational linguistics, and information retrieval, and for researchers entering these fields.

Author : Francis Yin Yee Lau,Craig Kuziemsky
Publisher : Unknown
Page : 487 pages
File Size : 48,7 Mb
Release : 2016-11
Category : Medical care
ISBN : 1550586017

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Handbook of EHealth Evaluation by Francis Yin Yee Lau,Craig Kuziemsky Pdf

To order please visit https://onlineacademiccommunity.uvic.ca/press/books/ordering/

Author : Edna K. Huffman
Publisher : Unknown
Page : 788 pages
File Size : 49,5 Mb
Release : 1990
Category : Electronic
ISBN : OCLC:636835383

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Medical Record Management by Edna K. Huffman Pdf

Author : Anonim
Publisher : Unknown
Page : 560 pages
File Size : 54,5 Mb
Release : 1999
Category : Cancer
ISBN : UOM:39015053160324

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Self Instructional Manual for Cancer Registrars by Anonim Pdf