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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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PubMed1977

A computerized prenatal record.

An entirely computerized ambulatory medical record system is operational in a large health maintenance organization. A unique subsystem was designed for use in prenatal care, in which the provider's completion of a single encounter form at the time of visit meets all the information requirements of care delivery, administration, and quality assurance. Instead of using a conventional paper chart, computer-generated summaries and flow charts are automatically provided for scheduled visits and for use as a hospital preadmission record, significantly reducing the provider effort expended on record keeping. On-line inquiry function is also available using terminals at the ambulatory center and the hospital. The computer data base has been used for quality assurance studies in prenatal care. The system is well accepted by providers, is reliable, and is cost effective.

Computers↗
PubMed1977

Occupational therapy sequential client care recording system: a comparative study.

The client care record is a key document for determining standards of care in occupational therapy. The purpose of this study was to determine the effectiveness of a client care recording system for occupational therapy that combined the theoretical framework of the Developmental Analysis, Evaluation and Intervention Schedule, and the scientific method of the Problem Oriented Medical Record. The research form of the client care record was compared to a traditional client care record in current use in an occupational therapy clinic. An interdisciplinary panel of health professionals rated both the original and proposed form of the record on the variables of completeness, organization, understandability, and usefulness. The findings show statistically significant differences between the client care record based on the combined Developmental Analysis, Evaluation and Intervention Schedule and the Problem Oriented Medical Record and the currently used record system.

Child↗
PubMed1977

A record keeping system addressing future needs.

Important long-range decisions regarding the provision of dental care and the education of dentists and dental para-professionals will be made by the government and third parties. The quality and interpretation of the data to be used depend on who gathers it. If the dental profession is not in the position to gather the data, others certainly will be. There is a wealth of statistical data in the records of every practice. The record keeping system described provides an organized way to get such information out, with a minimum of additional effort. Rather than making it a series of separate tasks to generate a statistical description of the practice population, the incidence of problems, or the progression of treatments, this record keeping system provides a single comprehensive method. This method grows with a practice, whether individual, group, or clinic. By doing this, it provides a long-range continuous monitor of the practice population and the problems incident to it. The installation of such a methodology in clinics and dental school faculty practices will rapidly contribute to our knowledge regarding dental health care. Adoption in whole or in part by private practioners will provide them with new tools for the delivery of better dental care and practice management.

Dental Care↗
PubMed1977

The SOAP revolution.

Explore the source record for details and available documents.

Medical Records, Problem-Oriented↗
PubMed1977

An on-line clinical information system in family practice.

An interactive on-line clinical information system is in operation within the residency of the Department of Family Practice at the Medical University of South Carolina in Charleston. This approach eliminates some of the traditional sources of error in collecting clinical information. Particular attention is given to flexibility of data presentation: data may be segregated by time, by disease entity, by age and sex of the patient, by physician, by year of residency, and by disease class. The responsiveness of this on-line technology allows the production of complete, up-to-date practice reports within 24 hours of a request.

Adolescent↗
PubMed1975

Upper-respiratory tract complaint protocol for physician-extenders.

A protocol for upper-respiratory tract complaints was administered to 226 patients in a walk-in clinic. The protocol, for use by a physician-extender in conjunction with a physician, specified the collection of data necessary for management. A decision-making algorithm separated the major causes of upper respiratory infection (URI) complaints and led to one of four plans: a physician referral, a culture only, antibiotic treatment, or symptomatic treatment only. Each patient was seen by a physician following the health assistant's interview. Of 226 patients, 96 (42 percent) would have been sent home by the protocol without seeing the physician. None of these had a complication of URI. Sixteen (seven percent) of the 226 had serious complications - all would have been referred to the physician. The protocol proved to be safe and efficient, acceptable to patients, and a reliable approach to physician-extender management of URI.

Anti-Bacterial Agents↗
PubMed1976

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↗