Research means improving health care delivery.
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Ambulatory Care↗
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Results for “Medical Records, Problem-Oriented”
Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.
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Protocol management of male genitourinary infections.
As part of a demonstration study, 567 male patients presenting to a "walk-in" clinic with common genitourinary complaints were interviewed by health assistants guided by a protocol. Independent examination of 19 patients by a health assistant and a physician formally demonstrated that the health assistants could collect the clinical data accurately. Forty-four patients were then randomly chosen to be examined, diagnosed and treated either by a health assistant guided by the protocol and supported by an available physician, or only by a physician. Using medical records and a follow-up interview, we assessed the thoroughness of the medical record, adequacy of diagnosis and treatment, symptom relief, patient satisfaction and patient education: the health assistant-protocol system proved as safe and effective as the MD-only system, and the health assistants were able to manage 68% of patients without involving the physician. The study suggests that briefly-trained health assistants may help save physician and nurse time, and that the development of protocols can help set standards for the medical management of defined problems while providing a mechanism for rapidly creating a complete medical record which can be easily audited for conformance with standards.
Adolescent↗
Problem-specific coding systems.
The data found in medical records, particularly in problem-oriented records, could yield very useful information for many aspects of the health care delivery system. Unless the tools and methods used in the analysis of health care data are very carefully designed, the potential value of this information cannot be fully realized. Coding is a critical step in the process of converting medical record data into useful information. This paper presents six criteria as design goals for a standard, comprehensive, coherent set of nomenclatures, classifications, taxonomies, and corresponding coding schemes for the analysis of medical and administrative record data. These goals are: compatibility with established routine operating procedure, health care problem specificity, hierarchical structure, economy through articulation of the components with one another and through the similarities in various aspects of health care delivery, and adaptability to change.
Classification↗
[Trends in the improvement of the medical documentation system].
The paper reports on the general and specific functions of medical records, as well as on the need to improve medical recording and the circulation of medical records in health units. The economic medical and social advantages of keeping accurate records are highlighted. Recent breakthroughs in information science permit unifying and standardizing medical records, making them more problem-oriented, developing technical equipment and extending its use in archives, expanding the role of the computer in clinical recording.
Documentation↗
The problem-oriented record for rehabilitation personnel.
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Medical Records↗
The problem-oriented postmortem examination.
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Autopsy↗
Introduction of the problem-oriented record into a child psychiatric hospital.
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Accreditation↗
New premises and new tools for medical care and medical education.
Medical care and medical education can be supported more than in the past by using new tools and new premises for the effective linkage between bodies of knowledge and the use of that knowledge. The medical record can be converted from a source-oriented record to a problem-oriented record, enabling to trace not only what was done, but why it was done. These possibilities reveal new insights in the use of databases, problem lists, problem-oriented plans, and problem-oriented progress notes and flowsheets. It brings about a new behavior in teaching which replaces memorizing facts, new possibilities for medical care, and new responsibilities both for physicians and patients. We now have knowledge-coupling tools that can be used directly with the patients at the time of problem solving. Patients are becoming active participants in this process, bringing about new roles for experts as well as expert systems.
Education, Medical↗
Integration of pharmacy into the computerized problem-oriented medical information system (PROMIS)--a demonstration project.
The integration of pharmacy into the computerized problem-oriented medical information system (PROMIS) at the Medical Center Hospital of Vermont is discussed. Practioners who generate and retrieve information communicate directly with the computer without intermediary personnel. Touch-screen cathode-ray tube terminals are used for data input. Under PROMIS, the pharmacist has two new resources which better integrate his services into total patient care: (1) the ability to directly access online patient data in the pharmacy, and (2) the ability to directly couple online current drug information to a specific patient's computerized medical record in the pharmacy. The PROMIS solutions to pharmacy problems in drug ordering, drug distribution and drug therapy audit are discussed; In a demonstration project on a 20-bed unit, PROMIS made the medical record readily available to all health care providers, reduced reliance on memory, preserved the logic of medical action, and provided feedback loops for corrective action in everyday medical practice. Also discussed are user acceptance of the system, effect on pharmacy staffing, and implications for pharmacy.
Computers↗
Functional status evaluation form: development and implications.
A medical audit revealed marked deficiency in the quality of functional evaluations in a rehabilitation hospital. Routine staff educational programs and an optional, simple functional evaluation form failed to correct this deficiency. The functional evaluations of the patients never reached 100% completion and the quality of the evaluations varied widely. As a result, a mandatory functional status form was devised for incorporation into the patients' charts. This form included past, present, and future goals in a problem-oriented design. Review of charts after six months of use showed that the form led to improved rates of functional status reporting, with all functional areas now documented in over 90% of charts. It is hoped that a comprehensive program including use of functional status form will be successful in improving patient care and physician education, and in facilitating a comprehensive medical audit.
Activities of Daily Living↗
System-structured management of acutely ill surgical patients.
The management of surgical patients requiring intensive care is complicated by abnormalities in multiple body systems. An effective method of organizing data collection and treatment is essential. The widely applied "problem-oriented" approach is not entirely satisfactory in the context of surgical intensive care. An alternative method is presented in which management is structured by body systems. The function of each system is analyzed and a plan for each is defined. Data display is arranged by systems rather than problems and is compatible with modern computer technology. A surgical patient under treatment for pancreatitis is presented to illustrate this approach. Experience with 220 patients on a residency teaching service supports the impression that system-structured management is an effective method of managing the course of an acutely ill patient and should be widely applicable to such patients in any general surgical environment.
Acute Disease↗
Establishing a quality improvement process for identification of psychosocial problems in a primary care practice.
OBJECTIVES: A quality improvement process that will significantly increase the rate of identification of psychosocial problems through routine use of case-finding instruments can be established in a general medicine practice. DESIGN: Two groups of patient examination reports written by physicians were retrospectively compared with the patients' responses on the case-finding database instrument. The samples were obtained by sequential selection in four time periods. SETTING AND PATIENTS: The study occurred in a university general internal medicine practice that utilizes the problem-oriented record. The patients studied were seen for first-time comprehensive examinations designed to identify all important health problems, including psychosocial problems. INTERVENTION: The authors compared performances of the physicians in identification of psychosocial problems before and after the intervention, which consisted of a pilot study audit of psychosocial problem identification, establishment of standards for interpretation of the case-finding instrument, design of a flow sheet to make case-finding data clearly available to the physician at each comprehensive examination, and feedback of physician performance according to practice-adopted standards for identification of psychosocial problems. MEASUREMENT: The result of the intervention was an increase in psychosocial problem identification from 67% to 90% of problems present, p less than 0.05 by chi-square distribution; or a decrease from 33% to 10% in psychosocial problems missed by the physicians. CONCLUSION: The quality improvement process for identification of psychosocial problems described in this report significantly increased the rate of identification of psychosocial problems by general internists.
Adolescent↗
Problem-oriented surgical audit in the community hospital. A concept in evolution.
A system of surgical audit based on identification and solution of surgical problems is described. The system relies initially on universal review of patient records on a monthly basis by surgeons in the involved institution. Evolution of the system to one which the records of certain patients can be excluded from review by physicians is seen as practical, if careful definition of such records is maintained. Emphasis on the goal of meaningful quality of care assessment is critial. Utilizing this system, surgeons in Stamford, Connecticut, have found significant deficiencies in diagnostic, therapeutic, or both of these aspects of patient care in 5 per cent of records reviewed. Ninety-five per cent of patients were judged to have had no important inadequacies in their surgical care, based on evidence in their medical records. Attempts to evaluate surgeons' behavioral changes, when deficiencies in their patients' care have been demonstrated, are being pursued actively.
Connecticut↗
Clinical evaluation of foot and ankle dysfunction.
Patients with foot and ankle dysfunction require a systematic approach in the evaluation process. An outline of the procedure is provided using the problem-oriented record system as a basis. Subjective data describe the patient's feelings toward the problem and goals concerning it. Objective data encompass several areas, including a detailed history; general posture; soft tissue structures; functional capacity; and the circulatory, musculoskeletal, and neuromuscular systems. The data are reviewed, and an accurate assessment of the nature and cause(s) of the dysfunction are made. Realistic goal statements are then written to prepare for successful treatment planning.
Ankle Joint↗
29. The Multi-State Information System for Psychiatric patients.
The Multi-State Information System for Psychiatric Patients (MSIS) is a computer based, clinical and administrative management information system used by numerous mental health programs and facilities for patient and program management. Structured forms are used for the collection of core information on patients, on services rendered, on affiliated agencies, and on fiscal and administrative processes. A variety of output reports and general retrieval techniques are being used to help administer and evaluate patient care programs, monitor clinical and program management functions, refer clients to other service agencies, and review individual cases, as well as for administrative functions such as cost finding, rate setting, billing, and inventory control. MSIS is currently field testing an automated problem-oriented psychiatric record, and a goal-oriented record to be used with the mentally retarded is under development.
Humans↗
A multidimensional problem-oriented review and evaluation system.
The need for evaluation of psychiatric services is becoming more and more apparent as third-party coverage becomes more available. A variety of expensive and complex data and computer systems have been developed. Small institutions and programs, however, cannot afford them. The system described in this report uses diagnosis and a standardized problem list in order to define the treatment outcome of a variety of therapies delivered in an interdisciplinary setting. The system, which has been developed and is operating at low cost, satisfies a variety of needs.
Ambulatory Care↗
[Use of a computerized problem-oriented record in special ambulatory periodontal treatment].
Starting from the development trends of the modern out-patient treatment it is required to clearly out-line the objective functions of special out-patient care in the periodontology. Of course, the represented function call for more comprehensive data acquisition in regard of the individual patient. As a model we have worked out a computer-aided problem-oriented record for periodontal care which, in a ring hybrid study, is now being tested by 14 different public health institutions of the GDR. Our problem-oriented record comprises the following parts: a) Patient-machine communication for anamnesis b) Computer-oriented medical record c) Automated synoptic presentation of problem epicrisis d) Centralized data-pool.
Ambulatory Care↗