发布求助
文献互助 智能选刊 最新文献

Chinese Medical Record English Edition最新文献

筛选
英文 中文
Problems in Conversation Records of the Internal Medicine System and the Management Strategies 内科系统会话记录存在的问题及管理对策
Chinese Medical Record English Edition Pub Date : 2014-07-31 DOI: 10.3109/23256176.2014.942974
Tinghui Xie, L. Gai, Qin Guo, Renl Zhou, Duo Wang
{"title":"Problems in Conversation Records of the Internal Medicine System and the Management Strategies","authors":"Tinghui Xie, L. Gai, Qin Guo, Renl Zhou, Duo Wang","doi":"10.3109/23256176.2014.942974","DOIUrl":"https://doi.org/10.3109/23256176.2014.942974","url":null,"abstract":"AbstractObjective. To analyze problems in medical conversation records and discuss management strategies. Method. Problems in 203 conversation records of five departments, generated from August 2013 to November 2013, were classified statistically. Results. A total of 39 conversation records were defective, accounting for 19.2% (39/203); of the 39 records, one problem occurred in 29 copies, accounting for 14.3% (29/203) and two or more problems occurred in ten copies, accounting for 4.9% (10/203). There were 54 problems in all the conversation records; each record had an average of 1.4 problems (54/39), and 69.2% (27/39) of the defective records were those of incomplete communication. Conclusion. Medical workers should carry out their duty of full medical disclosure, take medical conversations seriously and maintain written records, thereby improving the quality of medical records and reducing medical disputes.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116331340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Implementation of Appointment System for Medical Record Copying 病案复印预约制度的实施
Chinese Medical Record English Edition Pub Date : 2014-07-31 DOI: 10.3109/23256176.2014.945278
Xiaoqing Zhou, Lanzhen Cao, Xiao Yang, Xiaomei Fang, Xingchen Ming
{"title":"Implementation of Appointment System for Medical Record Copying","authors":"Xiaoqing Zhou, Lanzhen Cao, Xiao Yang, Xiaomei Fang, Xingchen Ming","doi":"10.3109/23256176.2014.945278","DOIUrl":"https://doi.org/10.3109/23256176.2014.945278","url":null,"abstract":"AbstractPatients request an appointment for medical record copying in person or by telephone; the medical record staff accurately register the information of patients through an identity check, and send patients an SMS reminder to collect the medical records; these methods can enable patients to get the copies of the medical records easily, and ensure that the medical record information is complete. This work reflects the “patient-centered” service concept, reduces the time spent by the patients in waiting to copy medical records, effectively improves the efficiency of medical record copying, ensures that patients can get the copied materials of medical records at the appointed time, and improves the service levels and patient satisfaction.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128417700","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 1
Information Platform-Based Outpatient Process Optimization of Large General Hospitals 基于信息平台的大型综合医院门诊流程优化
Chinese Medical Record English Edition Pub Date : 2014-07-31 DOI: 10.3109/23256176.2014.945271
W. Zheng, L. Zhao
{"title":"Information Platform-Based Outpatient Process Optimization of Large General Hospitals","authors":"W. Zheng, L. Zhao","doi":"10.3109/23256176.2014.945271","DOIUrl":"https://doi.org/10.3109/23256176.2014.945271","url":null,"abstract":"AbstractThe content and form of the outpatient service at general hospitals should meet the higher standards of diversified development in modern society. This article summarizes the optimization and upgrades of an outpatient process based on the construction of an informatized network. The optimized and upgraded process includes various pre-examination self services, inter-examination services and post-examination services, and a “patient-centered” outpatient process has been created to provide a convenient and efficient hospital environment for patients. The article also shows that safeguard from systems, delicacy management, and wide publicity laid the foundation for process optimization. There are, however, unavoidable existing or upcoming problems such as registration scalping, additional inter-examination registration, and patients going back and forth many times for examinations; therefore, further theoretical research should be done and further improvement should be made during practice. Consequen...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"44 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134485418","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Problems in Usage of Medical Terminology in Physical Examination Records and Relevant Improvement Measures 体检记录中医学术语使用的问题及改进措施
Chinese Medical Record English Edition Pub Date : 2014-07-31 DOI: 10.3109/23256176.2014.945272
Yu Sun, Qinghua Hu, Bin Zhou, Dongxing Miao
{"title":"Problems in Usage of Medical Terminology in Physical Examination Records and Relevant Improvement Measures","authors":"Yu Sun, Qinghua Hu, Bin Zhou, Dongxing Miao","doi":"10.3109/23256176.2014.945272","DOIUrl":"https://doi.org/10.3109/23256176.2014.945272","url":null,"abstract":"AbstractPhysical examination results need to be systematically and truly \u2028recorded with standardized terminology. The main problems existing \u2028in the recording process include: (1) recording with non-standard \u2028medical terms; (2) wrong description; (3) reversal of recording order; \u2028(4) incomplete recording; (5) ambiguous wording; (6) name of the disease or symptom instead of signs; (7) lack of objective and true recording; (8) classifying severity of signs in an ambiguous manner; (9) description being too simple; and (10) controversial recording. We should improve the understanding of the importance of language standardization, pay attention to the standardization training of clinical skills, constantly update medical and humanistic knowledge, improve management of systems, read many excellent textbooks from presses and examples set by medical journal editors to realize the standardization of medical terminology in physical examination records.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116652095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 1
Analysis of Online Report Data of Death Cases in 2009–2013 in the Emergency Department of a General Hospital 某综合医院急诊科2009-2013年死亡病例在线报告数据分析
Chinese Medical Record English Edition Pub Date : 2014-07-31 DOI: 10.3109/23256176.2014.945273
Chao Gui, Hui-qing Chen, Chunliang Zhou
{"title":"Analysis of Online Report Data of Death Cases in 2009–2013 in the Emergency Department of a General Hospital","authors":"Chao Gui, Hui-qing Chen, Chunliang Zhou","doi":"10.3109/23256176.2014.945273","DOIUrl":"https://doi.org/10.3109/23256176.2014.945273","url":null,"abstract":"AbstractObjective. To discuss the distribution of the epidemiological characteristics of the death cases in the emergency department such as age, gender, occupation, and the basic cause of death, and to provide the basis for the improvements in abilities to treat and cure critically ill emergency cases and the stipulation of preventive measures. Methods. Through the national cause-of-death registration reporting information system and according to the International Classification of Diseases (ICD-10), the 2009–2013 report data about the death cases in the emergency department of a general hospital were analyzed. Results. A total of 43.83% of the 2,763 death cases of the emergency department were an elderly group of people ranging in ages from 60 to 79 and only 3.47% of the 2,763 death cases were a young group of people of age less than or equal to 44; the male-female ratio was 1.18: 1; the basic causes of death were mainly diseases of the circulatory system (49.84%) and malignant neoplasms (22.26%); the o...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128735224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Effect of Step-by-step Quality Control on the Quality of Electronic Medical Records 分步质量控制对电子病历质量的影响
Chinese Medical Record English Edition Pub Date : 2014-07-31 DOI: 10.3109/23256176.2014.945264
Wei He, Yankai Ma, Yunna Ma, Xian Li
{"title":"Effect of Step-by-step Quality Control on the Quality of Electronic Medical Records","authors":"Wei He, Yankai Ma, Yunna Ma, Xian Li","doi":"10.3109/23256176.2014.945264","DOIUrl":"https://doi.org/10.3109/23256176.2014.945264","url":null,"abstract":"AbstractObjective. To explore the effect of step-by-step quality control on the quality of electronic medical records. Method. To randomly extract 6,200 final medical records generated from July 2012 to December 2012 and 6,200 electronic medical records generated from January 2013 to June 2013, after step-by-step quality control is implemented in the network, to track the quality of the final medical records after step-by-step quality control. The final medical records are checked and evaluated according to the Basic Criterion of Documentation of the Medical Record issued by the Ministry of Health; the quality of medical records, defects in real-time, and writing defects are analyzed statistically. Results. Compared with the medical records generated from July 2012 to December 2012, the rate of grade A medical records generated from January 2013 to June 2013 is increased by 4.46% (P < 0.01), the rate of grade B medical records is decreased by 4.43% (P < 0.01), and the rate of grade C medical records is de...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"15 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126521130","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Design and Implementation of Follow-up Management System for Malignant Tumor Patients 恶性肿瘤患者随访管理系统的设计与实现
Chinese Medical Record English Edition Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.932075
Chenyu Wang, Yufeng Jia, Zhangguo Shen
{"title":"Design and Implementation of Follow-up Management System for Malignant Tumor Patients","authors":"Chenyu Wang, Yufeng Jia, Zhangguo Shen","doi":"10.3109/23256176.2014.932075","DOIUrl":"https://doi.org/10.3109/23256176.2014.932075","url":null,"abstract":"AbstractAccording to the requirements of the hospital's practice, a follow-up management system for malignant tumor patients is developed. It is based on the C/S model in the local area network, and can be visited through the TCP/IP protocol and Microsoft SQL server ADO; it is developed with the application of Microsoft Visual Basic 6.0 as a development tool and Microsoft SQL Server 2000 as a database management tool. The operation of the system is simple and convenient, which greatly reduces the time to process original data and can promptly collect the diagnostic and treatment information of outpatient and hospitalization practices; by using the operation system, excessive effort can be avoided; besides, it is convenient for statistics and enquiries, thus greatly improving the accuracy and efficiency of follow-up.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130305253","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Effects of the Quality Control Circle Applied in the Quality Control of Nursing Records of Critically Ill Patients 品管圈在危重病人护理记录质量控制中的应用效果
Chinese Medical Record English Edition Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.933585
H. Tang, Jiling Xu, Pei-lin Jiao, Jing Chen, Li Zhao, Lei Jiang, Xue Wang
{"title":"Effects of the Quality Control Circle Applied in the Quality Control of Nursing Records of Critically Ill Patients","authors":"H. Tang, Jiling Xu, Pei-lin Jiao, Jing Chen, Li Zhao, Lei Jiang, Xue Wang","doi":"10.3109/23256176.2014.933585","DOIUrl":"https://doi.org/10.3109/23256176.2014.933585","url":null,"abstract":"AbstractObjective. To discuss the effects of the quality control circle applied in the quality control of nursing records of critically ill patients. Methods. A quality control circle team was set up, taking “to improve the quality of nursing records of critically ill patients” as the theme, to analyze the major influences attributing to the quality of the nursing records, set goals, take corrective measures, evaluate the achievements, and so on. Results. After the quality control circle was set up, the number of Grade A nursing records of critically ill patients increased (P < 0.01), and the numbers of Grade B and Grade C nursing records of critically ill patients decreased (P < 0.01); the satisfaction over the quality control of nursing records increased from 92.2% to 97.8% (P < 0.01). Conclusion. The quality control circle is capable of effectively improving the quality of nursing records of critically ill patients.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125966692","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Discussion on the Necessity of Making Quality Presentation of Medical Records 浅谈病案质量呈现的必要性
Chinese Medical Record English Edition Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.933579
Jing Su, Yanyan Zhu, Yajun Hong, D. Chen
{"title":"Discussion on the Necessity of Making Quality Presentation of Medical Records","authors":"Jing Su, Yanyan Zhu, Yajun Hong, D. Chen","doi":"10.3109/23256176.2014.933579","DOIUrl":"https://doi.org/10.3109/23256176.2014.933579","url":null,"abstract":"AbstractThe quality presentation of medical records has important implications for the department of medical records in a hospital, and the accurate information could provide a reference both for the decision-making by leaders and for the purposes of treatment, teaching and research; it is a new breakthrough in improving the work efficiency of the medical record staff and also an effective publicity method to promote the overall image of the department. Medical record administrators should pay full attention to this work and give full play to their advantages; through carefully studying the needs of “users”, screening valuable original information, designing reasonable statistical report tables, collecting accurate data and analyzing them, the medical record administrators can assist the hospital leaders to straighten out the workflows in the hospital, improve the work efficiency of each position, ensure the accuracy of medical information data and provide powerful data support.","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"148 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128607001","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Contrastive Analysis of Clinical Blood Transfusion Records Before and After Intervention 干预前后临床输血记录对比分析
Chinese Medical Record English Edition Pub Date : 2014-07-01 DOI: 10.3109/23256176.2014.933581
F. Ren, Zharova Ma, Li Guo, Rendong Liu
{"title":"Contrastive Analysis of Clinical Blood Transfusion Records Before and After Intervention","authors":"F. Ren, Zharova Ma, Li Guo, Rendong Liu","doi":"10.3109/23256176.2014.933581","DOIUrl":"https://doi.org/10.3109/23256176.2014.933581","url":null,"abstract":"AbstractObjective. To achieve better standardization in the writing of blood transfusion records and improve the safety of clinical blood transfusions by studying clinical blood transfusion records. Methods. Transfusion records were modified and interventional steps were taken, and final clinical transfusion records were randomly inspected. Results. Of a total of 1,280 transfusion records, 982 were qualified and 298 were unqualified, with 438 records qualified out of 640 transfusion records prior to intervention and 544 records qualified out of 640 transfusion records following the intervention; the pass level of the transfusion records increased from 68.44% to 85.00%. There was a significant difference (P < 0.05) between the transfusion records prior to and following the intervention. Conclusion. Since the transfusion records were found to have varying degrees of imperfection and the indications for transfusion were not obvious, the hospital should enhance the training provided to medical staff on the tr...","PeriodicalId":163748,"journal":{"name":"Chinese Medical Record English Edition","volume":"109 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2014-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130314250","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
首页 上一页 下一页 尾页
0
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整，为了账户安全，请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
现在去查看 取消
×
提示
确定
请完成安全验证×
相关产品
×
本文献相关产品
联系我们：info@booksci.cn Book学术提供免费学术资源搜索服务，方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号：481959085
Book学术官方微信