Topics in health record management最新文献

{"title":"Implementing a clinical information system.","authors":"E H Curtis,&nbsp;V R Patterson","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The design of CIS utilizing the hospital's network allows for the flexibility of providing clinicians with on-line access to additional valuable patient information. The acceptance of CIS and the continuing demand for access to CIS are excellent indicators that development of this system was well worth the efforts of the individuals and teams involved in the planning, design, and implementation of CIS. Although it cannot replace the traditional paper medical record, CIS certainly is being recognized as a timely and reliable resource for the communication of patient information in the Ohio State University's numerous patient treatment facilities.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"10-21"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984743","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}

{"title":"Euthanasia in The Netherlands: medical record documentation requirements.","authors":"C K Smith","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"45-51"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984745","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}

{"title":"The professional image of medical record practitioners: perceptions from administrative officers, financial officers, and chiefs of medical staffs.","authors":"B K Brunner","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The study's findings provide insights into the relationship between medical record practitioners and the disciplines whose members were surveyed. This relationship is an important one. Much has been written about the team concept in the provision of care. Teamwork and maintaining a mutually respectful relationship is just as important to the administrative aspects of health care. A positive professional image is a prerequisite for gaining respect. Nurturing a positive professional image is the responsibility of individual practitioners as well as the medical record profession as a collective entity. One way in which these findings can be utilized is for self analysis of MRPs: how would they evaluate themselves and how they perceive others would evaluate them. Answers to these questions may suggest areas where improvement in necessary. A second way in which findings can be used is in the recruitment arena. Positive findings can be used as recruiting and marketing tools to attract potential members into the medical record profession. Efforts in the recruitment area are necessary to meet predicted manpower shortages in the profession. While the study assisted in the understanding of the relationship of MRPs and other professionals with whom they must work closely, further study is necessary. This study's response rate and limitations to the parameters may preclude generalization; therefore, replication of the study is needed before findings can be universally applied. Additional study is necessary to determine others' perceptions of not only the image of MRPs but the identity as well. Are MRPs perceived as safekeepers of medical records or as health information leaders?</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"22-8"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21032337","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}

{"title":"Forum: In sickness and in health--the role of the ICD in the United States health care data and ICD-10.","authors":"K M Weigel,&nbsp;C A Lewis","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"70-82"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21054926","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}

{"title":"Legal review: The Patient Self-Determination Act--\"Miranda\" rights in health care.","authors":"M C Gaughan","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The Patient Self-Determination Act should help patients make their own health care decisions without the intervention of the courts. Health care providers will acquire a large responsibility for helping to educate the public concerning the availability and use of advance directives. It is hoped that the additional investment providers will make in administering the provisions of the Act will bear dividends in better informed patients and in loss of time and suffering avoided when health care decisions are required for incapacitated patients.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"83-8"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20982831","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}

{"title":"Case study: development of a forms-design guidebook.","authors":"K H Seckinger","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Implementation of the approval and official format of medical record forms procedure along with the use of the forms-design guidebook will result in a forms-management program that will be efficient and effective. This program is sufficiently detailed to provide forms that are consistent and useful. The procedure will provide the necessary documentation for forms control and will facilitate an approval process that is standardized and faster than before. An overview of the steps taken to complete this project are listed in the box entitled \"Steps for Revision of Forms-Control Process.\" The control of medical record forms will provide documents that are useful and accurate for purposes of communication and planning of quality patient care and will meet the requirements of licensing and accrediting agencies. Also, the concentration on the consideration of cost throughout this project will reduce costs by improved efficiency in the paperwork system and by reducing both the production and the usage costs of forms.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"29-44"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984744","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}

{"title":"Sources of stress and coping mechanisms of medical record students.","authors":"B J Petterson,&nbsp;B K Brunner,&nbsp;E K Stich","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"12 1","pages":"60-9"},"PeriodicalIF":0.0,"publicationDate":"1991-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984747","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}

{"title":"Standards for the electronic transfer of clinical data: progress and promises.","authors":"C J McDonald,&nbsp;D K Martin,&nbsp;J M Overhage","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Data exchange standards have two components: the message format or syntax and the dictionary of codes (semantics). For many applications, message standards already have been developed. For a few kinds of clinical entities, such as drugs, these code systems (e.g., the National Drug Code) are virtually complete, but a few gaps must be filled and an agreement must be reached about the level of granularity needed. The available codes for clinical descriptors are inadequate but the National Library of Medicine's Universal Medical Language (UML) project will do much to redress this deficiency. Codes for clinical variables such as blood pressure and blood glucose which have methods, units, normal ranges, and physiologic correlates are very inadequate. CPT4 provides some of the needed codes but has huge gaps. An early effort to extend CPT4 is included in ASTM 1238. Work being done by ASTM E31.12 and the Euclides project will offer robust codes for clinical laboratory measurements. If we want to pool data from different institutions for clinical and policy research, universal codes for observations are prerequisite. And agreement of an international coding system for observation-bearing variables should be a major agenda item for standards groups in the next year. Our goal has been to standardize the communication of clinical data between clinical systems, not the systems themselves or their internal operation. In fact, standardizing the internals of clinical application could be counterproductive at the present. It would deflect energy from, and delay the spread of, CDI standards. Moreover, it gives undue attention to computer systems, rather than the data they contain. The data are the most expensive part of any data system. They are the raison d'être for such systems. Computer systems come and go. The data last forever. Yet we have been mesmerized by the computer system while ignoring its contents. As a result, most computer-stored clinical data must live like the tragic boy in the bubble. They cannot \"live\" outside of the computer system in which they were born. So, we find at every hospital the bizarre rituals of humans reading computer-generated reports so they can type this information in another computer. Electronic (e.g., stored clinical) data should not depend upon the internals of a particular program, language, or machine for its interpretation. The clinical data entered into one computer system should be directly available to any other computer system that now receives them through manual transcription. Data interchange standards give life to our data--independent of the source system.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"11 4","pages":"1-16"},"PeriodicalIF":0.0,"publicationDate":"1991-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984096","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}

{"title":"Innovations and research review: insights on hospital medical record managers using personality analysis.","authors":"B J Petterson","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>In general, the hypotheses presented at the onset of the study were supported by the results reported here. Over 75 percent of the medical record managers surveyed were from facilities of less than 300 beds. Findings are consistent with characteristics of supervisors in small-to medium-sized departments. The most unique finding relates to the overrepresentation of NP managers in the larger facilities. The NP manager has a global, innovative perspective but also may have trouble coming to closure on projects and decisions. This managerial type will quite easily find other intuitive managers. Other perceiving managers will be found much less frequently and the perceiver must be prepared to have this perspective viewed as unique by other managers who are predominantly Js. Further research is needed to provide detailed explanations for this portion of the results. The majority of this group were classified in the SJ temperament grouping. More sensors were found among ARTs, in smaller facilities, and in the hospital medical record department manager population as a whole when compared to other managers. These findings provide insights that must be recognized and evaluated by the profession as it looks to the future and focuses on long-term goals. This research focuses on hospital medical record managers, only one of many groups that make up the medical record profession. Additional studies are needed to verify results and to evaluate individuals in other hospital medical record positions and in other settings, as well as other allied health managers. This research does, however, provide the basis for future comparisons.</p>","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"11 4","pages":"73-84"},"PeriodicalIF":0.0,"publicationDate":"1991-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984104","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}

{"title":"Forum: continuous quality improvement in health care.","authors":"B McBride","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":79757,"journal":{"name":"Topics in health record management","volume":"11 4","pages":"85-8"},"PeriodicalIF":0.0,"publicationDate":"1991-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20984105","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}