Dissertations / Theses on the topic 'Patient records'

Reading an electronic patient record (EPR) is a very challenging task because of the medical jargons, which are almost impossible to understand for the layman. This becomes a highly relevant challenge because of the more extensive use of the internet to get medical information. Also the Norwegian laws state that the patient has the right to read his or her own EPR. A master thesis executed in 2006, and a specialization project in 2007 addressed this subject and developed a prototype for adapting EPRs to a patient presentation. This thesis continues this work and aims to extend the system with more functionality and improve the translation of the EPRs. The main issues discussed in the thesis are how disambiguating between Norwegian words and medical terms, provide summaries of EPRs, and supply the patient with external information about his or her health condition. In addition the refined user interface from the specialization project was implemented. The conclusion of this thesis is that the Support Vector Machine classifier with character bigrams provides good and accurate disambiguation between Norwegian words and medical terms. The external information functionality provides correct and quality assured information from the patient hand book. There are still some issues, and possible improvements on providing only precise and relevant articles. Summarizing of EPRs is achieved through named entity extraction of ICD codes, and then presenting the codes together with their corresponding descriptions. This implementation seems to be accurate, correct, and precise.

The health and social care sector has a continuous growth in the use of information technology. With more and more information about the patient stored in different systems by different health care actors, information sharing is a key to better treatment. The introduction of the personal health record aims at making this treatment process easier. In addition to being able to share information to others, the patients can also take a more active part in their treatment by communicating with participants through the system. As the personal health record is owned and controlled by the patient with assistance from health care actors, one of the keys to success lies in how the patient can control the access to the record. In this master's thesis we have developed an access control model for the personal health record in a Norwegian setting. The development is based on different studies of existing similar solutions and literature. Some of the topics we present are re-introduced from an earlier project. Interviews with potential users have also been a valuable and important source for ideas and inspiration, especially due to the fact that the access control model sets high demands on user-friendliness. As part of the access control model we have also suggested a set of key roles for the personal health record. Through a conceptual implementation we have further shown that the access control model can be implemented. Three different solutions that show the conceptual implementation in the Indivo personal health record have been suggested, using the Extensible Access Control Markup Language as the foundation.

Within the field of medical informatics, patient medical records are the sole source of information for dealing with clinical activities concerning the documentation, care, progression, and ongoing interactions between the patient and clinicians. Electronic or computer-based patient records (CPRs) have had a presence within health care in some form and magnitude for the past thirty years yet only recently have been incorporated in health care to a larger extent. Due to the wide variation of professions in health care, there is a problem of CPRs not being able to fulfill all the possibilities and demands the individual professionals need, since many CPRs are designed as a generic system, to be used across multiple professions.

The focus of this report is on the utilization of a generic CPR in a specialist clinical setting, i.e., a physical therapy clinic, and to analyze how the therapists utilize the different components and features in a generic CPR. The purpose of the evaluation was to investigate how viable the CPR was as a documentation tool and to which extent it supported the therapists in their clinical, documentation and delivery of care activities. In this study, a total of seven physical therapists participated in a post-usage evaluation of an existing CPR. The evaluation was achieved by interpretative research with open-ended interviews and observations. The results of the study showed that despite some shortcomings, the generic CPR was an effective tool for the clinicians, not only as a documenting aid, but also enabling them to quickly research the patients' prior diagnosis and treatment history, plan for future care, support decision-making and to communicate with other professionals so as to coordinate treatment and planning.

Den dokumentation som görs i patientjournaler får allt större betydelse för patientens säkerhet och delaktighet samt för uppföljning och utveckling av vårdens kvalitet. IT-stöd ökar informationens tillgänglighet, men studier visar på brister vad gäller struktur och innehåll.

Syftet med denna studie var att kartlägga i vilken omfattning dubbeldokumentation förekom i den tvärprofessionella, elektroniska patientjournalen, relaterat till sjuksköterskans dokumentation (delstudie I), samt att undersöka personals uppfattningar om dubbeldokumentation och värdet av att använda egen och annan professions dokumentation (delstudie II).

Studien genomfördes på ett länsdelssjukhus där datorjournaler använts i ca 10 år. Trettio strokepatienters journaler analyserades utifrån VIPS-modellens sökord och arbetsterapeuter, läkare, sjukgymnaster och sjuksköterskor (N = 111) besvarade en studiespecifik enkät.

Resultatet visade att 15 % av innehållet i omvårdnadsdokumentationen (exklusive epikris) också fanns dokumenterat på annan plats i journalen, en eller flera gånger. Av omvårdnadsanamnesernas innehåll var 43 % dubbeldokumenterat. Motsvarande andel för omvårdnadsstatus och omvårdnadsåtgärder var 6 % respektive 10 %. När det gäller omvårdnadsepikriserna var 41 % av innehållet även dokumenterat i annan professions epikris. Dubbeldokumentationer förekom oftare mellan sjuksköterska och läkare än mellan sjuksköterska och arbetsterapeut/sjukgymnast. Samtliga professioner ansåg det värdefullt att kunna ta del av varandras dokumentation. Läkarens dokumentation följdes i stor utsträckning av alla. Arbetsterapeuter, sjukgymnaster och sjuksköterskor följde varandras dokumentation i stor utsträckning. Det var vanligare att man sökte specifik information än läste dokumentationen för att skaffa sig en helhetsbild. Sjuksköterskor sökte också ofta information för att i sin tur lämna denna vidare. Dubbeldokumentation ansågs förekomma mest inom journalens anamnesdel. Tänkbara orsaker till dubbeldokumentation ansågs vara att man inte läser vad andra har dokumenterat, att man vill visa vad som gjorts samt att diktaten skrivs in för sent. Vid jämförelse mellan sjuksköterskor med äldre utbildning respektive de med utbildning enligt 1993 års studieordning visades att sjuksköterskor med äldre utbildning instämde i högre utsträckning till att dubbeldokumentation ofta förekommer mellan läkare och sjuksköterska.

För att undvika onödig dubbeldokumentation krävs, förutom att aktuell information finns tillgänglig, att roller och ansvarsförhållanden mellan professionerna tydliggjorts.

The documentation made in patients’ charts is becoming of greater importance for the safety and involvement of patients and for the follow up and development of the quality of care. IT support increases the accessibility of information, but studies even show deficits pertaining to structure and content. The aim for this study was to survey to what extent double documentation occurs in multiprofessional, electronic patient charts, related to the nurse’s documentation and to investigate staffs’ understanding of the value and usage of other professionals’ documentation.

The study was conducted at a county hospital where computer charts have been in use for about 10 years. Thirty stroke patients’ charts were analysed on the basis of the VIPS models key words and occupational therapists, physicians, physiotherapists, and nurses completed a study specific survey.

The results showed that 15% of the content in nursing care documentation (excluding epicrisis) was also documented in other places in the chart, one or more times. Of the content of the nursing anamnesis 43% were double documented. The corresponding share of the nursing status and nursing interventions were 6% respectively 10%. When it comes to nursing epicrisis 41% of the content was also documented in other professionals’ epicrisis. Double documentation occurs more often between nurses and physicians than between nurses and occupational therapists/physiotherapists.

All of the occupations considered that it is valuable to be able to take part in each others documentation. Physicians’ documentation was followed to a great extent by all. Occupational therapists, physiotherapists, and nurses followed each others documentation to a great extent. It was more common to seek specific information that to read the documentation in order to acquire an overall picture. Nurses sought also often information which in turn was given to others. Double documentation was considered to occur mostly in the section of the chart for anamnesis. Conceivable reasons for double documentation were considered to be caused by not reading what others had documented, to show what had been done, and that dictation was written in too late. At a comparison between nurses with an older education and those with an education according to the 1993 curriculum showed that nurses with an older education agreed to a greater extent that double documentation occurred between physicians and nurses.

Avoiding unnecessary double documentation demands, besides that current information is available, that the conditions of rolls and responsibilities between professionals are clarified.

Personal health record (PHR) is considered a crucial part in improving patient outcomes by ensuring important aspects in treatment such as continuity of care (COC), evidence- based treatment (EBT) and most importantly prevent medical errors (PME). Recently there has been more focus on preventive care or monitoring and control of patients symptoms than treatment itself. Nowadays, there are many mobile health applications and sensors such as blood pressure sensors, electrocardiogram sensors, blood glucose measuring devices, and others that are used by the patients who monitor and control their health. These apps and sensors produce personal health data that can be used for treatment purposes. If managed and handled properly, it can be considered patient-generated data. There are other types of personal health data that are available from various sources such as hospitals, doctors offices, clinics, radiology centers or any other caregivers.

Aforementioned health documents are deemed as a PHR. However, personal health data is difficult to collect and manage due to the fact that they are distributed over multiple sources (e.g. caregivers, patients themselves, clinical devices, and others) and each may describe patient problems in their own way. Such inconsistencies could lead to medical mistakes when it comes to the treatment of the patient. In case of emergency, this situation makes timely retrieval of necessary personal clinical data difficult. In addition, since the amount and types of personal clinical data continue to grow, finding relevant clinical data when needed is getting more difficult if no actions are taken to resolve such issue. Having complete and accurate patient medical history available at the time of need can improve patient outcomes by ensuring important aspects such as COC, EBT, and PME. Despite the importance of PHR, the adoption rate by the general public in the U.S. still remains low. In this study we attempt to use Personal Health Record System (PHRS) as a central point to aggregate health records of a patient from multiple sources (e.g. caregivers, patients themselves, clinical devices, and others) and to standardize personal health records (e.g. use of International Classification of Diseases (ICD- 10) and Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT)) through our proof-of-concept model: Health Decision Support System (HDSS).

We started out by exploring the barriers in adopting PHRs and proposed a few approaches that can promote the adoption of PHRS by the general public so it is possible to implement continuity of care in community settings, evidence-based care, and also prevent potential medical errors. To uncover the barriers in adopting PHR, we have surveyed articles related to PHRS from 2008 to 2017 and categorized them into 6 different categories: motivation, usability, ownerships, interoperability, privacy, and security and portability.

We incorporated the survey results into our proposed PHRS, so it can help overcome some of the barriers and motivate people to adopt PHRS. In Our proposed PHRS, we aimed to manage personal health data by utilizing metadata for organizing and retrieval of clinical data. Cloud storage was chosen for easy access and sharing of health data with relevant caregivers to implement the continuity of care and evidence-based treatment. In our study, we have used Dropbox as storage for testing purposes. However, for practical use, secure cloud storage services that are Health Insurance Portability and Accountability Act (HIPAA) complaint can be used for privacy and security purposes, such as Dropbox (Business), Box, Google Drive,Microsoft OneDrive, and Carbonite. In case of emergency, we make critical medical information such as current medication and allergies available to relevant caregivers with valid license numbers only. In addition, to standardize PHR and improve health knowledge, we provide semantic guidance for using SNOMED CT to describe patient problems and for mapping SNOMED CT codes to ICD-10-CM to uncover potential diseases. As a proof of concept, we have developed two systems (prototypes): first, my clinical record system (MCRS) for organizing, managing, storing, sharing and retrieving personal health records in a timely manner; second, a health decision support system (HDSS) that can help users to use SNOMED CT codes and potential disease(s) as a diagnosis result.