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Journal articles on the topic 'Medical records'

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Author: Grafiati

Published: 4 June 2021

Last updated: 1 August 2024

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1

R, Abinandana, and Srinivasa Reddy P. "Medical Records- a Legal Perspective." JOURNAL OF CLINICAL AND BIOMEDICAL SCIENCES 08, no. 4 (December 15, 2018): 109–12. http://dx.doi.org/10.58739/jcbs/v08i4.7.

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A medical record is a document containing chronologically written account of a patient’s examina-tion and treatment. A medical record apart from case sheet includes investigatory reports, investigatory samples, referral letter, discharge summary etc. Every registered medical practitioner is supposed to main-tain the proper medical report of his / her patient. The Indian government has laid down certain guidelines as to properly preserve the records. As a component of good medical practice it is necessary to maintain the medical records anticipating the litigation anytime. Key words: Medical records, Documentation, Electronic medical records, Medico legal report.

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2

Carpenter, Iain, Mala Bridgelal Ram, Giles P. Croft, and John G. Williams. "Medical records and record-keeping standards." Clinical Medicine 7, no. 4 (August 1, 2007): 328–31. http://dx.doi.org/10.7861/clinmedicine.7-4-328.

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3

Reddy, BH Srinivas, Dr J. N. Rao Dr.J.N.Rao, and Dr B. V. Subrahmanyam Dr.B.V.Subrahmanyam. "Medical Records –Boon Or Bane." Paripex - Indian Journal Of Research 2, no. 2 (January 15, 2012): 238–39. http://dx.doi.org/10.15373/22501991/feb2013/84.

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4

Minda Kusumah, Raden, and Jessica Putri Meyliyan. "Review Of Returning Medical Records In Outpatient Medical Record." KESANS : International Journal of Health and Science 1, no. 1 (October 30, 2021): 6–12. http://dx.doi.org/10.54543/kesans.v1i1.3.

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In returning the outpatient medical record file to thesection of the Medical Record Unit, Assembling there was a delay. This is because the return of medical record files has not been carried out according to Standard Operating Procedures, as a result, causing delays in the reporting system. The method used is qualitative using a descriptive approach. Data collection techniques by observation, interviews and literature study. This study aims to determine the return of former medical records of outpatients at Dayeuhkolot Health Center. The results of the study prove that the delay in returning outpatient medical record files at the Dayeuhkolot Health Center with presentations during the 1 week study amounted to 63 or 22% of 285 medical record files. Efforts have been made to disseminate information to all officers related to the efforts made by the person in charge of COVID-19 patients in returning medical record files on time.

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5

Cahalane, Seamus, James Deeny, and John O'Connell. "Medical Records." Books Ireland, no. 133 (1989): 115. http://dx.doi.org/10.2307/20626192.

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6

Nilegaonkar, Sujit, and PadmajS Kulkarni. "Medical records." Indian Journal of Medical and Paediatric Oncology 41, no. 1 (2020): 47. http://dx.doi.org/10.4103/ijmpo.ijmpo_49_20.

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7

TAN, S. Y. "Medical Records." Family Practice News 41, no. 14 (September 2011): 62–63. http://dx.doi.org/10.1016/s0300-7073(11)70788-5.

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8

Lane, Vic, and Peter Hayward. "Medical records." Lancet 353, no. 9149 (January 1999): 330. http://dx.doi.org/10.1016/s0140-6736(05)74890-x.

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9

Tan, S. Y. "Medical Records." Internal Medicine News 44, no. 12 (July 2011): 68. http://dx.doi.org/10.1016/s1097-8690(11)70632-1.

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10

Michael, Robin. "Paperless Medical Records." Australian Medical Record Journal 19, no. 4 (December 1989): 149–54. http://dx.doi.org/10.1177/183335838901900404.

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Flinders Medical Centre (FMC) in South Australia has a storage problem. The space available for filing existing medical records is full, while the demand for additional storage continues its linear growth. The hospital plans to use this “crisis” as an opportunity to review the entire basis for the management of the medical record and pilot an optical disk system as a precursor to paperless medical records. There are many constraints to this objective, but many advantages if the scheme proves successful. Michael describes the events which precipitated this project and outlines the steps in FMC's planned progression to a paperless record. (AMRJ, 1989, 19(4), 149–154).

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11

Md Zali, Mastura, Saiful Farik Mat Yatin, Mohd Razilan Abdul Kadir, Siti Noraini Mohd Tobi, Nurul Hanis Kamarudin, and Nik Nurul Emyliana Nik Ramlee. "Managing Medical Records in Specialist Medical Centres." International Journal of Engineering & Technology 7, no. 3.7 (July 4, 2018): 232. http://dx.doi.org/10.14419/ijet.v7i3.7.16358.

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A collection of facts about a patient’s life and health history of past and present illnesses and treatments is known as medical records. The health professionals were contributing to record the patient’s care. The responsibility in managing daily records that produced by each of department is by the Medical Records Department. It is a department under clinical support services with activities including managing of patient records, patient information production, management of medical reports, and hospital statistics. This article aims to discuss the challenge associated with managing medical records in the organization and how to handle and manage it with the records management as a tool to mitigate risk. Therefore, it is likely to prompt further research by addressing existing gaps towards improving service delivery that can contribute to the body of knowledge in the field of records management and archives generally.

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12

Slaughter, Jim. "The Medical Records Professionalsʼ View of the Electronic Medical Record." Journal of Ambulatory Care Management 23, no. 2 (April 2000): 18–26. http://dx.doi.org/10.1097/00004479-200004000-00004.

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13

Ballance, Dennis W., Paul R. Brentson, and Janet Aldrich. "The Electronic Medical Record: Medical Records That Teach Communication Skills." Journal of Veterinary Medical Education 33, no. 1 (March 2006): 81–84. http://dx.doi.org/10.3138/jvme.33.1.81.

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14

Pagano, Michael P., and David Mair. "Writing Medical Records." Journal of Technical Writing and Communication 16, no. 4 (October 1986): 331–41. http://dx.doi.org/10.2190/wy9t-634e-v2jt-jdvq.

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A study was undertaken both to evaluate how medical students are taught to write patient records and to examine the writing done by doctors. Typical medical records, written by medical doctors, were also evaluated. A single questionnaire was sent to eighty-four medical school professors, twenty law school faculty, and five practicing attorneys. The questionnaire asked how medical records were used and what the legal implications were in authoring a patient record. The medical professionals were also asked how their schools taught medical writing. The questionnaire pointed out that most medical schools teach less than ten hours of medical writing in their curricula and that patient records are not written with an understanding of the various audiences, purposes, and uses for medical documents. Two radiology reports are discussed in terms of their clarity and usefulness for medical and extra-medical readers. The study concludes that medical students should be taught a composing process so that they will understand the audience, purpose, and use for the patient records they write.

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15

Anggraeni, Devina, and Muhammad Ikhsan. "The Role of Electronic Medical Records as Evidence in Medical Disputes in Hospitals." SOEPRA 5, no. 2 (April 2, 2020): 311. http://dx.doi.org/10.24167/shk.v5i2.2428.

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Medical Record is a file that contains records and other documents such as patient identification, examination, the treatment that has been given to the patient. Based on the Minister of Health No. 269/MENKES/PER /III / 2008 concerning the medical record that there are two types of medical records that conventional medical records and electronic medical records. With the absence of a strong legal basis related to the setting of electronic medical records, but in reality, many hospitals are using electronic medical records which raised the question, how the role of electronic medical records as evidence in the medical dispute that occurred in the hospital ?. This study uses Descriptio with the normative juridical approach. The data used is qualitative. This is done to get an overview of the roles of electronic medical records as evidence in the medical dispute in the hospital. Electronic medical records in the case of medical dispute resolution in the hospital can not be made as evidence in the medical case settlement, because the regulations related to the use of electronic medical records alone do not yet have a clear legal basis.

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16

Malakar, Rajib. "Electronic medical records." Indian Journal of Dermatology 51, no. 2 (2006): 140. http://dx.doi.org/10.4103/0019-5154.26940.

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17

Potts, Jerry F. "Electronic medical records." Postgraduate Medicine 101, no. 2 (February 1997): 31–36. http://dx.doi.org/10.3810/pgm.1997.02.154.

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18

Callan, Laura, and Nancy Chen. "Electronic Medical Records." University of Western Ontario Medical Journal 82, no. 2 (July 30, 2014): 31–32. http://dx.doi.org/10.5206/uwomj.v82i2.4605.

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19

Trimmer, Ken, Leigh W. Cellucci, Carla Wiggins, and William Woodhouse. "Electronic Medical Records." International Journal of Healthcare Information Systems and Informatics 4, no. 3 (July 2009): 55–68. http://dx.doi.org/10.4018/jhisi.2009070104.

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20

Marks, Eric S. "Poor Medical Records." Annals of Internal Medicine 110, no. 12 (June 15, 1989): 1037. http://dx.doi.org/10.7326/0003-4819-110-12-1037_1.

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21

ESSIN, DANIEL J., and CECELIA D. ESSIN. "Computerizing medical records." Critical Care Medicine 18, no. 1 (January 1990): 100–102. http://dx.doi.org/10.1097/00003246-199001000-00021.

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22

Shrader, J. A. "Computerized medical records." Academic Medicine 63, no. 12 (December 1988): 928–9. http://dx.doi.org/10.1097/00001888-198812000-00011.

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23

McCOY, MICHAEL JAMES. "Electronic Medical Records." Clinical Obstetrics and Gynecology 55, no. 3 (September 2012): 605–12. http://dx.doi.org/10.1097/grf.0b013e31825ca574.

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24

Claeys, Patricia M. "Electronic Medical Records." Gastroenterology Nursing 30, no. 2 (March 2007): 144. http://dx.doi.org/10.1097/01.sga.0000267956.75759.ce.

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25

Whitlock, Ginger H. "Electronic medical records." Journal of Ambulatory Care Management 15, no. 3 (July 1992): 76–80. http://dx.doi.org/10.1097/00004479-199207000-00008.

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26

Hochheiser, Harry, and Ben Shneiderman. "Electronic medical records." Interactions 18, no. 6 (November 2011): 48–49. http://dx.doi.org/10.1145/2029976.2029989.

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27

Rutberg, Martin P. "MEDICAL RECORDS CONFIDENTIALITY." Neurologic Clinics 17, no. 2 (May 1999): 307–13. http://dx.doi.org/10.1016/s0733-8619(05)70133-x.

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28

Diamond, Edward, Kim French, Cynthia Gronkiewicz, and Marilyn Borkgren. "Electronic Medical Records." Chest 138, no. 3 (September 2010): 716–23. http://dx.doi.org/10.1378/chest.09-1328.

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29

&NA;. "Electronic medical records." Nursing 42, no. 12 (December 2012): 6. http://dx.doi.org/10.1097/01.nurse.0000422666.28231.8d.

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30

Frampton, Susan B., Sheryl Horowitz, and Barbara J. Stumpo. "Open Medical Records." AJN, American Journal of Nursing 109, no. 8 (August 2009): 59–63. http://dx.doi.org/10.1097/01.naj.0000358504.52667.71.

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31

Smith, Mike. "Protecting Medical Records." ITNOW 60, no. 4 (2018): 14–15. http://dx.doi.org/10.1093/itnow/bwy089.

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32

Avitzur, Orly. "ELECTRONIC MEDICAL RECORDS." Neurology Today 2, no. 5 (May 2002): 30–31. http://dx.doi.org/10.1097/00132985-200205000-00011.

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33

Steward, Melissa. "Electronic Medical Records." Journal of Legal Medicine 26, no. 4 (December 2005): 491–506. http://dx.doi.org/10.1080/01947640500364762.

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34

Smith, James F. "Occupational Medical Records." AAOHN Journal 42, no. 1 (January 1994): 18–22. http://dx.doi.org/10.1177/216507999404200105.

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35

Tevaarwerk, G. J. M. "Electronic medical records." Canadian Medical Association Journal 178, no. 10 (May 6, 2008): 1323. http://dx.doi.org/10.1503/cmaj.1080032.

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36

Greiver, M. "Electronic medical records." Canadian Medical Association Journal 178, no. 10 (May 6, 2008): 1323–24. http://dx.doi.org/10.1503/cmaj.1080033.

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37

Viner, G., and A. Parush. "Electronic medical records." Canadian Medical Association Journal 179, no. 1 (June 12, 2008): 54. http://dx.doi.org/10.1503/cmaj.1080036.

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38

Heinlein, Edwin B. "Medical records security." Computers & Security 15, no. 2 (January 1996): 100–102. http://dx.doi.org/10.1016/0167-4048(96)89322-9.

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39

Kolpan, Kenneth I. "Disclosing medical records." Journal of Head Trauma Rehabilitation 4, no. 3 (September 1989): 95–96. http://dx.doi.org/10.1097/00001199-198909000-00016.

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40

Charney, Pamela. "Electronic Medical Records." Nutrition in Clinical Practice 27, no. 6 (October 18, 2012): 715–17. http://dx.doi.org/10.1177/0884533612464784.

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41

Double, D. B. "Editing medical records." BMJ 303, no. 6805 (September 28, 1991): 787. http://dx.doi.org/10.1136/bmj.303.6805.787-b.

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42

Huang, Jeannie S., and Catharine M. Walsh. "Electronic Medical Records." Gastrointestinal Endoscopy Clinics of North America 33, no. 2 (April 2023): 267–90. http://dx.doi.org/10.1016/j.giec.2022.11.004.

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43

Kristina, Indah, and Ambarwati. "PENATA LAKSANAAN PENYIMPANAN REKAM MEDIS DI PUSKESMAS PISANGAN." MEDICORDHIF Jurnal Rekam Medis 9, no. 1 (July 15, 2022): 104–8. http://dx.doi.org/10.59300/mjrm.v9i1.86.

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The implementation of Community Service activities at the Pisangan Health Center aims to assist the management of the health center's medical record storage, especially the shrinkage of medical records, carried out according to plan and running smoothly. This activity was carried out in collaboration with the Pisangan Health Center. Activities include observing the storage room, the number of shelves is sufficient to accommodate active medical records, there is no indication for storing medical records, there is no outguide, tracer, medical records with family folders, currently in the process of transitioning to individual folders. Medical records that have been destroyed have not yet been made. Minutes of the destruction have not been made. assistance in assessing 7039 family folder medical records and 3031 individual medical records still in the active medical record category. The recommendations submitted were making an official report on the destruction of medical records that had been destroyed, using the guidelines for managing medical record shrinkage at the Puskesmas, completing supporting equipment for storing medical records, rearranging the alignment of medical records using final numbers and placing medical records in sub shelves according to their capacity. Access to Medical Records repository. Keywords: management, storage, medical records

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44

Ta Duy, Ngoc, Anh Le Thi Kim, and Thinh Nguyen Huu. "The quality of obstetrics medical record documentation in a unit during the transition to electronic medical records." Journal of Health and Development Studies 07, no. 06 (December 29, 2023): 105–12. http://dx.doi.org/10.38148/jhds.0706skpt23-101.

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To assess the quality of inpatient obstetrics medical record documentation and analyze the factors affecting it at the University Medical Center Ho Chi Minh City - Branch 2. A cross-sectional study was conducted to evaluate 195 inpatient obstetrics medical records from June 2023 to August 2023, in-depth interviews were carried out with 6 healthcare staff members at the hospital. The overall quality of recording general medical records is 21.5%; in the administrative information section, it is 80.5%; in the medical record section, it is 80.5%; the content of medical orders and their implementation is 52.8%, and the overall summary of medical records is 67.2%. The rate of complete documentation varies for medical records that use health insurance and service medical records. Factors influencing the quality of medical record keeping include the age and gender of healthcare staff, workload, multiparous women with comorbidities, training processes, and monitoring of medical record keeping. The quality of medical record-keeping is low, with the lowest being in the content of medical orders and their implementation. Training and training programs need to be organized for new healthcare staff, and regular monitoring checks for paper medical record keeping should be implemented. At the same time, the rapid development of electronic medical records should be undertaken to reduce the time spent on documentation and integrate the process of implementing medical orders for patients.

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45

Anggorowati, Rita, Tiny Rahayu, Muhammad Irfan Nur Arif, Kiki Muhammad Rizki, Adithya W. P. Lucky, Abil Sabila Rosyad, and Andini Zahra Hafizhah. "Inactive medical record management at Bandung Hospital." International journal of health sciences 6, no. 3 (September 30, 2022): 1520–26. http://dx.doi.org/10.53730/ijhs.v6n3.13160.

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The purpose of this study was to examine the management of inactive medical records in a private hospital in Bandung. The research method used is descriptive-analytic. The research subjects were the head of the medical records section and the storage officer. The results of the study were in inactive medical record storage in the form of microfilm and USB as well as computer notebooks. The medical record room does not have room temperature control, humidity control room, and lighting settings. Maintain the cleanliness of the medical record room and inactive medical records. There is no treatment for inactive medical record files, air exchange, and medical record maintenance. Storage of inactive medical records uses a centralized and decentralized system. Requirements for inactive medical record storage rooms for temperature control, storage cabinets, and room humidity do not use regulators, and there is no supervision.

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46

Widiarta, Marselinus Gede, I. Putu Dedy Kastama Hardy, and Ni Kadek Yunita Sari. "ANALISIS KELENGKAPAN BERKAS REKAM MEDIS DI PUSKESMAS KUTA UTARA." ARCHIVE OF COMMUNITY HEALTH 9, no. 3 (December 26, 2022): 480. http://dx.doi.org/10.24843/ach.2022.v09.i03.p10.

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ABSTRACTEvery health facility, from primary/primary, secondary, tertiary levels is required to maintain medical records. Medical records are an important part of health services. The quality of medical records also determines the quality of health services. The North Kuta Health Center is one of the health centers in Badung Regency whose medical records have not yet reached 100%. The purpose of this study was to describe the completeness of patient identification and authentication of medical record files at the North Kuta Health Center and identify factors that affect the completeness of patient identification and authentication of medical record files. The research method used is a quantitative and qualitative method with a sequential explanatory design. The research sample based on the slovin formula was 92 medical record files. There were seven informants consisting of doctors, nurses, midwives, registration officers and medical records officers. The results showed that the average completeness of filling in patient identification and authentication of medical record files was quite complete but still less than the standard of completeness set by the Indonesian Ministry of Health of 100%. The lack of special training on filling out medical records, the occurrence of human errors due to lack of awareness and discipline of officers in filling out medical record files, patients not carrying identities, lack of socialization of SOPs for filling medical records, and the absence of sanctions for officers who do not fill out medical record files completely are factors that affect the completeness of patient identification and authentication of medical record files. So it is advisable to socialize the SOP for filling out medical records intensively, giving warnings or sanctions to officers who do not fill out medical record files completely and giving awards to officers who fill out medical records completely.Keywords : Completeness, factors, Medical Records, Health Services

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47

Katile, Urvashi. "MediChain: Medical Record Management System." International Journal for Research in Applied Science and Engineering Technology 11, no. 5 (May 31, 2023): 3414–17. http://dx.doi.org/10.22214/ijraset.2023.52365.

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Abstract: Currently, Electronic Health Records are managed using a client-server architecture by which healthcare providers retain data stewardship. But this strategy has problems with security and privacy, a single point of failure, fragmented data, and susceptibility. Blockchain is a brand-new, developing technology for distributed databases that uses cryptography to ensure the security, incorruptibility, and integrity of data. These characteristics allow secure and reliable data storage. Blockchain-based record management system uses smart contracts to ensure the privacy of patients. This health record management platform will store the user’s hospital, lab, pharmacy, and insurer records. It will increase the speed of information storing and exchange So that all patients can easily access individual medical records in different hospitals and clinics. This will help doctors and patients with diagnoses and also various insurance companies to check the medical records by getting access to records from the platform and also this will help the researchers and scientists.

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48

Houston, Michael. "The Psychiatric Medical Record, HIPAA, and the Use of Electronic Medical Records." Child and Adolescent Psychiatric Clinics of North America 19, no. 1 (January 2010): 107–14. http://dx.doi.org/10.1016/j.chc.2009.08.011.

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49

Mardi, Yuli. "Electronic Medical Record as Literature Study." Proceeding International Conference on Medical Record 2, no. 1 (January 10, 2022): 45–51. http://dx.doi.org/10.47387/icmr.v2i1.154.

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Background: Medical records can be created manually or electronically. In the world of health, the development of information and communication technology is currently affecting health care services as a whole, including the implementation of electronic medical records. The application of electronic medical records must go through a careful planning stage, this is because electronic medical records involve many parties in health facilities and and require a lot of costs. For this reason, a comprehensive study of electronic medical records is needed. One way is to conduct a literature study of several articles related to the electronic medical record.Methods: In conducting this research, the literature review method was used, where the search for articles was not carried out systematically, but the scientific journal articles reviewed were selected by the researcher on one research topic, and selected based on the knowledge and experience possessed by the researcher (traditional review).Results: In this study, 7 articles were reviewed related to electronic medical records. There are some similarities in terms of benefits or obstacles in the application of electronic medical records in health facilities. Among the benefits of electronic medical records are the efficiency of using paper/medical record files, efficiency in the use of space/storage media, time efficiency in searching data and distributing medical record data, efficiency of human resources in finding medical record files and being able to detect errors in data entry. While some of the common obstacles to implementing electronic medical records in health facilities are the unpreparedness of officers at health facilities, so it takes time for socialization and training of human resources, problems with the network, lack of IT resources at health facilities that specifically handle electronic medical records, high implementation costs. expensive (hardware software) and there is no legal umbrella.Conclusions: There is a need for comprehensive research using the semantic review method of articles related to electronic medical records, so that the results can be used as a reference for health facilities in implementing electronic medical records. Thus, it is hoped that the migration and implementation process from manual medical records to electronic medical records can be carried out as expected.

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50

Asih, Hastin Atas, and Indrayadi Indrayadi. "Transformation from Manual Medical Records to Electronic Medical Records: A Phenomenological Study." Contagion: Scientific Periodical Journal of Public Health and Coastal Health 6, no. 1 (February 15, 2024): 25. http://dx.doi.org/10.30829/contagion.v6i1.19188.

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<div><table cellspacing="0" cellpadding="0" align="left"><tbody><tr><td align="left" valign="top"><p><em>With the rapid advancement of information technology in the healthcare sector, the implementation of electronic medical records has become a dominating trend. The transition from manual medical records to electronic medical records is not just a technological transformation but also a revolution in healthcare services. This research aims to explore the hospital's experience in transitioning from manual medical records to electronic medical records at dr. R. Soeharsono hospital, a level iii hospital. This research utilizes a qualitative approach with a phenomenological design. Data collection is conducted through in-depth interviews, and data analysis follows the colaizzi method. Triangulation methods were carried out by means of interviews with electronic medical records users, document analysis, and field observations The study involves four participants. The results reveal four main themes: Benchmarking, Finding suitable service platforms, EMR facilities, EMR training and Implementation of EMR. Electronic medical records training emerges as a crucial factor in preparing for electronic medical records usage, supported by regulations mandating electronic medical records service platforms. The use of external service platforms is acknowledged as an effort to enhance data security. The success of the implementation of electronic medical records also relies on the availability of supporting facilities and the selection of the right service platforms. This research provides important insights for hospitals and related parties to understand the transformation process from manual medical records to electronic medical records optimally</em><em>.</em></p><p> </p></td></tr></tbody></table></div><p><strong><em>Keywords: Electronic Medical Record, technology</em></strong></p>

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