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Innovations and research review: the impact of the HELP computer system on the LDS Hospital paper medical record. 创新与研究综述:HELP计算机系统对LDS医院纸质病案的影响。
Topics in health record management Pub Date : 1991-11-01
G J Kuperman, B B Maack, K Bauer, R M Gardner
{"title":"Innovations and research review: the impact of the HELP computer system on the LDS Hospital paper medical record.","authors":"G J Kuperman,&nbsp;B B Maack,&nbsp;K Bauer,&nbsp;R M Gardner","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>This study sought to answer the question: What percentage of an LDS Hospital patient's chart is contained in the HELP system? Using the number of pages in the record as the criteria, the answer is about 26 percent overall, but between 35 percent and 40 percent for patients in nursing divisions where computerized nurse charting is used. Although this fraction is likely to rise in the near future, the critical factor driving computerization is the desire for data usable in computerized decision making rather than the need to computerize the entire chart per se. The medical record at LDS Hospital will probably be a hybrid of computerized and paper data for some time to come.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"76-85"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20987575","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
The role of medical staff credentialing in a risk management program. 医务人员资格认证在风险管理项目中的作用。
Topics in health record management Pub Date : 1991-11-01
V L Searcy
{"title":"The role of medical staff credentialing in a risk management program.","authors":"V L Searcy","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Because the courts have recognized that only the hospital and medical staff are capable of enforcing standards of professional performance, the hospital, board of directors, and medical staff must develop systems for determining who shall be allowed to practice and what procedures he or she will be allowed to perform. Practitioners do not enjoy an absolute right to practice merely because of licensure. Credentialing criteria reasonably related to considerations of patient care and hospital operations will almost certainly withstand judicial scrutiny.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"34-9"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20987566","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
Instituting a concurrent process for monitoring the clinical risk of physicians' practice. 建立监测医生执业临床风险的并行过程。
Topics in health record management Pub Date : 1991-11-01
G Stearns, E D Joseph
{"title":"Instituting a concurrent process for monitoring the clinical risk of physicians' practice.","authors":"G Stearns,&nbsp;E D Joseph","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>By implementing a more concurrent program for identifying and responding to situations that put patients at risk, such as the approach described in this article, hospital quality assurance and risk management professionals, as well as the medical staff and administration, may finally achieve the complementary goals of increasing the quality of clinical care while simultaneously reducing claims and suits against the hospital and its physicians.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"8-21"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21041988","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
Risk management: an overview. 风险管理:概述。
Topics in health record management Pub Date : 1991-11-01
N E Morgan
{"title":"Risk management: an overview.","authors":"N E Morgan","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>It is not known what the future holds for the health care industry in the way of risk. It is pretty clear that the environment is dynamic with daily, if not hourly, changes. Risk managers must be willing to meet the challenge to improve quality of care, meet the needs and expectations of patients and payors, and reduce the potential for loss.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"1-7"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20987563","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
Risk management: role of the medical record department. 风险管理:病案科的角色。
Topics in health record management Pub Date : 1991-11-01
H Feather, N Morgan
{"title":"Risk management: role of the medical record department.","authors":"H Feather,&nbsp;N Morgan","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Good record-keeping practices contribute to the high quality of the medical record. Is the medical staff actually aware of the multiple uses of the medical record today as opposed to only a few years ago? This is all in keeping with multiple requirements for accreditation, state licensing requirements, hospital medical staff rules and regulations, and a more aggressive consumer. Physicians and attorneys alike depend on the documentation in the medical record to support their case. An independent detailed recollection of the case by caregivers without use of the medical record would be extremely difficult. Nothing can take the place of an accurate account of the patient's care in the medical record. Defense in the absence of supporting documentation would be very weak, if not lost. It is clear that inadequate or incomplete medical records expose the physician and the hospital to risk. Hospital rules and regulations should be strictly enforced to enhance patient care and to avoid potential legal action. If documentation problems are identified, utilize the medical staff committees for recommendations and action. Medical records are an integral part of patient care responsibility and should be treated as such. The medical record is a legal document that is the most reliable record of care rendered to the patient. In legal settings, the record will be scrutinized by expert witnesses for the plaintiff and the defense. What the records do not contain may be as important as what they do contain when there is an allegation that the patient's condition warranted intervention or action that was not taken.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"40-8"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20987568","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
Trends in utilization management: legal implications for health records administration. 利用管理的趋势:对健康记录管理的法律影响。
Topics in health record management Pub Date : 1991-11-01
A G Gosfield
{"title":"Trends in utilization management: legal implications for health records administration.","authors":"A G Gosfield","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Utilization management will continue, under whatever label or within whatever framework, to demand the attention of records administrators. Since all quality and utilization review is ultimately based on the data in the medical record, the role of health record administrators is central to this activity. As programs and requirements continue to evolve, successful health care providers will draw on educated records professionals to assist in successful management strategies.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"22-33"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20987564","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
Risks associated with clinical databases. 与临床数据库相关的风险。
Topics in health record management Pub Date : 1991-11-01
P Y Eleazar
{"title":"Risks associated with clinical databases.","authors":"P Y Eleazar","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Providers will succeed who are evaluating themselves, and who are continuously striving to examine who they are and where they are going. Conscientious providers know that countless other agencies have them under the microscope and that they have to work to stay ahead in assessing their actions through their clinical database. \"Medical care value purchasing\" is what every employer and payor is looking for, and providers need to find ways to illustrate cost in relation to quality. The basics of data security and protection should be in place in order to concentrate on the bigger picture. The knowledge of the risk associated with individual hospital databases as well as the risk associated with comparative databases is critical. The hospital-level clinical database is the hub of the wheel. If the risk there can be minimized, the data headed for various investigative sites will have less inherent risk. When it is really recognized and accepted that all financial decisions are made based upon the clinical data generated at the site of care, then data integrity will become a strategic advantage for the industry. Clinical database goals will, over time, cause minimization of risk at all levels. As this occurs, variation in treatment will be explained artfully.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"49-58"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20987570","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
Risk management, safety management, and quality assurance. 风险管理、安全管理和质量保证。
Topics in health record management Pub Date : 1991-11-01
G M Rakes
{"title":"Risk management, safety management, and quality assurance.","authors":"G M Rakes","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The changes that have taken place in health care during the past few years have also created changes in our hospital safety programs. We can no longer address the safety issue as a dual function of a department manager. The safety management program plays an important role in the overall success of the quality of the facility. Safety is no longer a program that stands alone and oversees the fire safety program. To have a successful risk management and quality assurance program, safety management has to be included as an integral part.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 2","pages":"59-66"},"PeriodicalIF":0.0,"publicationDate":"1991-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20993245","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
Medical record review for clinical pertinence. 临床针对性的医疗记录审查。
Topics in health record management Pub Date : 1991-08-01
K S Lewis
{"title":"Medical record review for clinical pertinence.","authors":"K S Lewis","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>This clinical pertinence review process described was in effect for seven months, after which the author terminated affiliation with the hospital. Despite resistance by many physicians, this monthly review process focused the medical staff's attention on good documentation practices. To the author's knowledge, the plan is still in use.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"52-9"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984746","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
The impact of the HELP computer system on the LDS Hospital paper medical record. HELP计算机系统对LDS医院纸质病案的影响。
Topics in health record management Pub Date : 1991-08-01
G L Kuperman, B B Maack, K Bauer, R M Gardner
{"title":"The impact of the HELP computer system on the LDS Hospital paper medical record.","authors":"G L Kuperman,&nbsp;B B Maack,&nbsp;K Bauer,&nbsp;R M Gardner","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>This study sought to answer the question: What percentage of an LDS Hospital patient's chart is contained in the HELP system? Using the number of pages in the record as the criteria, the answer is about 26 percent overall, but between 35 percent and 40 percent for patients in nursing divisions where computerized nurse charting is used. Although this fraction is likely to rise in the near future, the critical factor driving computerization is the desire for data usable in computerized decision making rather than the need to computerize the entire chart per se. The medical record at LDS Hospital will probably be a hybrid of computerized and paper data for some time to come.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984742","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
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