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Results for “Medical Records, Problem-Oriented”

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At least 109 records · Page 6Linked to original sources
PubMed1977

A longitudinal chart audit of hypertension in a family practice center.

This is a paper in which a practice looks critically at itself through a longitudinal chart audit of 40 patients with hypertension of at least one year's duration. Diagnosis was properly made in all of the patients. The evaluation by physical examination and laboratory studies seemed appropriate and adequate. Therapy was effective. Optimal patient education toward eliminating risk factors was precluded by poor recording of the family history and past medical history of the patient. To overcome these deficiencies a new history data base sheet was designed and a chronic disease flow sheet was developed. This flow sheet is adaptable to any office practice setting and not only affords better patient care, but sets the stage for future prospective studies.

Adult↗
PubMed1977

[Patient-oriented information processing in internal medicine].

The internistic accessory documentation as a partial region of the information processing referred to the patient in a hospital fulfils the demands of diagnostic and therapeutic kind from the point of view of the hospital physician to rationalise and optimize the demands of administrative work, such as identification and duration of stay, and demands of the physician performing the follow-up treatment to get a quick and sufficient information with the threefold aim of treatment (including prevention, diagnostics and after-treatment), documentation (including statistics, archivation, information) and research (any connection of data for cross-section and longitudinal section examinations you like).

Germany, East↗
PubMed1977

[Experience and results in the evaluation of documentation-oriented medical records in the German Democratic Republic].

At the instance of the chronic liver diseases (Nr. 571 and 573 IKK) is shown in form of a model which high value of information the process of the stored data of the headline of a medical record suited for documentation. Thus informations concerning the clinical morbidity/mortality, analyses according to age and sex, residence and admitting institution, comparison of admission, treatment and post-mortem diagnoses, ascertainment of the diagnosis and finally economic data may be got. From this result the epidemiological conclusions and the statements for analyses of factors.

Adolescent↗
PubMedDate not supplied

Problem-orientation: an experimental study to test its heuristic value.

Using a two-group before--after experimental design, this study explored the effect of problem-orientation on a nursing staff's ability to identify underlying patient problems. Nursing service staff members (registered nurses, licensed vocational nurses, and corps personnel) from two small naval hospitals who met the criteria for inclusion and consented to participate were utilized. Because of staff turnover, the composition of the groups differed from preto posttesting phases. The pretest sample consisted of 47 control/48 experimental subjects; the posttest sample included 38 control/39 experimental subjects. The experimental group was instructed on the independent variable, problem-orientation, by the investigator through a six-hour workshop on the problem-oriented nursing record after which the system was instituted in the experimental setting. After a five-month period posttesting was done to determine if changes had occurred. Analysis of the data supported the hypothesis that problem-orientation does, in fact, substantially increase a nursing staff's ability to identify patient problems. The incorporation of this system into nursing services could provide a vehicle for pinpointing underlying patient problems and dealing with them in a systematic way, thereby upgrading patient care.

Evaluation Studies as Topic↗
PubMed1977

[Problem oriented pediatric record (author's transl)].

The object of this paper is the presentation of the problem griented medical record now in use at the Department of Pediatrics of the Faculty of Medicine of the University of Valencia. The main documents of this medical record (problem list, discharge summary, anamnesis and physical examination summary, and medical record summary) are given describing the characteristics of format and the rules for its completion. The relationships between the main documents are shown.

Child↗
PubMed1978

Information management in clinical practice.

Information management is essential for optimal delivery of health care services to individuals and the community. Current information techniques--largely dependent on the individual patient record--cannot effectively store, process, retrieve, and communicate the vast amount of data and information which is integral to the comprehensive health care process. Computerized techniques similar to those which are an indispensable part of almost all scientific, commercial, and administrative sectors of society are urgently needed to support a fully effective health care system.

Ambulatory Care↗
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↗