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Results for “Medical Records Systems, Computerized”

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At least 19 recordsLinked to original sources
PubMed1979

The computerized medical record system: meeting the challenge for nursing.

A system of computerized medical record-keeping in a health maintenance organization is described. Some problems arising in the shift from manual to computerized record-keeping are discussed. Perhaps the most important for nursing is the increase in the nursing staff's responsibility for complete, consistent documentation of patient care concomitant with the shift to a computerized system. Nurses must be comfortable with patient assessment, patient management and documentation in order to utilize the system effectively.

Computers↗
PubMedDate not supplied

Errors in a computerized medical records system (CLINICS).

The accuracy of computer-held medical information can be of critical importance in patient care, therefore it is important not only to know the error rate in the stored data but also to know the effectiveness of error checking and correction programs. This paper reports on the errors which were detected by checking the consistency between stored data and incoming data (context checks), in Southampton University Primary Medical Care computer system (CLINICS). The majority of detected errors were traced either to the registration of new patients or to the doctors failing to pay adequate attention to detail in their record keeping (or to their legibility). 7% of incoming data had errors detected by the context checking program and subsequently corrected; we calculate that the stored data contains less than 1% in error.

Computers↗
PubMed1979

The impact of a computerized medical record summary system on incidence and length of hospitalization.

The present study examined the influence of a computerized medical record summary system on incidence and length of hospitalization. Additional indicators of process of care were also considered. A prospective, randomized design was used where 241 experimental patients had a computerized medical record summary and 238 control patients had the traditional medical record. All patients were followed and compared over a two-year period. Although no difference in incidence of hospitalization was found between patients with and without the summary, during the second year, patients with summaries spent fewer days in the hospital. Patients with summaries also had more completed referrals for consultation, assigned diets, detected new problems and diagnostic tests on record than patients without the summary.

Chicago↗
PubMed1991

Increasing physician acceptance and use of the computerized ambulatory medical record.

Because physicians have been reluctant to accept computerized medical records systems, we sought to identify the barriers to acceptance and redesigned our ambulatory records system accordingly. We identified several problems physicians encounter in using our computerized medical record system (COSTAR), including physicians' hesitation to use a computer in front of their patients, physicians' poor keyboard skills, and the structural organization of the computerized medical record. We formed a users group to educate users and the group has helped identify solutions to these problems. We equipped the exam room terminals with a user-friendly, patient-specific menu. We created a new physician interface for COSTAR that was organized to function similarly to a patient's chart and features user-friendly menus that provide cues to the unsophisticated user. Physician use of exam room terminals tripled after the installation of the exam room menu. The new physician interface doubled physician use of COSTAR's scheduling features. Acceptance of the new interface as gauged by a user survey was excellent, with the majority stating it improved their patient care.

Academic Medical Centers↗
PubMed1990

[Electronic organization of patient records as a component of integrated medical informatics].

Conventional patient records are not only inconvenient to store, their structure is often not consistent and faulty, research is difficult and quality control is not possible. One solution to this problem is the computerized patient record. It contains all necessary data beginning with the first medical statements and ending with the final results of treatment. At any time and from any with the system connected computer terminal it allows immediate access to all medical records. In addition to medical information also administrative data are stored. The here presented system of a computerized medical record has proven to be an effective tool in the daily work as well for clinical, administrative and research tasks.

Humans↗
PubMed1992

A survey of university-prison collaboration and computerized tracking systems in prisons.

It is conservatively estimated that 8 percent of inmates in U.S. prisons have significant psychiatric impairment. Correctional mental health systems are often unable to provide adequate treatment to such inmates because of staff recruitment problems. Collaboration between universities and departments of corrections can help solve recruitment problems, and needs assessment studies and computerized tracking systems can help obtain needed resources. A national survey collected data on collaborations between universities and corrections departments and on needs assessment and computerized tracking systems in prisons. Results indicated that such collaborations exist in more than half of state prison systems. Of 42 states responding, only ten states reported having systemwide computerized tracking systems, but others are in the process of developing such systems. Two-thirds of the correctional mental health systems did not have an ongoing needs assessment program.

Antisocial Personality Disorder↗
PubMed1992

A computerized documentation system for cancer pain management units.

A cancer pain management unit can benefit markedly from a well-planned documentation system for administrative and scientific purposes. This article presents the principles of such a computerized system based on relational data base programs. The described system has been used by the authors for the last seven years. The successful documentation of more than 1400 patients over treatment periods of up to 2 years has provided detailed administrative and scientific information.

Algorithms↗
PubMed1991

Use of primary health care in Spili, Crete, and in Dalby, Sweden.

A computerized medical record system was introduced in Greek primary health care (PHC) in the village of Spili in Crete. The present study was carried out to study similarities and differences in the pattern of PHC use in Dalby Health Centre, Sweden (DHC), and Spili Health Centre, Greece (SHC). In both Dalby and Spili more than half the population contacted their respective health centre during 1989. Patients contacted DHC more often than SHC, 3.33 vs 2.30 times. Relatively more females than males used the health services in Dalby (64% vs 50%) but not in Spili (57% vs 55%). More visits were made by appointment at DHC than SHC (36.0% vs 12.6%). There were great similarities in the two areas in the ten most common diagnoses, analysed in four age-groups. In both areas, acute upper respiratory infections dominated in the youngest age-groups, and hypertension and diabetes in those aged 45 years and above.

Adolescent↗
PubMed1992

A computerised out-patient medical records programme based on the Summary Time-Oriented Record (STOR) System.

Advances in microcomputer hardware and software technology have made computerised outpatient medical records practical. We have developed a programme based on the Summary Time-Oriented Record (STOR) system which complements existing paper-based record keeping. The elements of the Problem Oriented Medical Record (POMR) System are displayed in two windows within one screen, namely, the SOAP (Subjective information, Objective information, Assessments and Plans) elements in the Reason For Encounter (RFE) window and the problem list with outcomes in the Problem List (PL) window. Context sensitive child windows display details of plans of management in the RFE window and clinical notes in the PL window. The benefits of such innovations to clinical decision making and practice based research and its medico-legal implications are discussed.

Humans↗
PubMedDate not supplied

Computerized medical records in family medicine journals, 1981-1990: diffusion of an innovation.

This study examined whether references to computerized medical records in family medicine journals had increased over the past decade as an example of diffusion of innovations. The abstract and methods sections of articles in Family Medicine, the Journal of Family Practice, and the Journal of the American Board of Family Practice were reviewed from 1981 to 1990 for explicit references to computerized medical records. The proportion of articles citing computerized medical records did not significantly increase overall or in any one journal during this time. Articles referenced computerized medical records with regard to sample selection for research studies (54%), description of computerized medical record systems (26%), and generation of health maintenance reminders (4%). These results are discussed in the context of family medicine literature and in terms of factors that typically impede the diffusion of innovations.

Diffusion of Innovation↗
PubMed1991

[Electronic data processing assisted documentation of tumor after care in an ambulatory setting--a simplification of daily routine].

A data collection system on microcomputer was developed for patients with malignant diseases in ambulant aftercare. At the same time when patient data are collected to be sent to a central medicostatistical plotting station, as it is usual in Austrian hospitals, a file for further aftercare is opened. By data transfer to other software products, statistical data evaluation is possible. Patients can also be called to hospital for different reasons.

Aftercare↗
PubMed1991

Non-categorical problem lists in a primary-care information system.

An ambulatory-care patient-tracking system has been implemented that records non-categorical problem descriptions in the outpatient problem list. The system does not restrict physicians to the use of predefined diagnostic categories. Instead, the system stores patient problems in a database as free-text records. Subsequent diagnostic categorization and coding is accomplished through prompted free-text input and appropriate reference databases. This system design allows an outpatient problem-list summary to reflect non-categorical health-status information in addition to coded medical diagnoses.

Ambulatory Care Information Systems↗
PubMed1991

Incorporating client-server database architecture and graphical user interface into outpatient medical records.

Computerized medical record systems require structured database architectures for information processing. However, the data must be able to be transferred across heterogeneous platform and software systems. Client-Server architecture allows for distributive processing of information among networked computers and provides the flexibility needed to link diverse systems together effectively. We have incorporated this client-server model with a graphical user interface into an outpatient medical record system, known as SuperChart, for the Department of Family Medicine at SUNY Health Science Center at Syracuse. SuperChart was developed using SuperCard and Oracle SuperCard uses modern object-oriented programming to support a hypermedia environment. Oracle is a powerful relational database management system that incorporates a client-server architecture. This provides both a distributed database and distributed processing which improves performance.

Ambulatory Care Information Systems↗
PubMed1991

Foundations for an electronic medical record.

Given the many efforts currently under way to develop standards for electronic medical records, it is important to step back and reexamine the fundamental principles which should underlie a model of the electronic medical record. This paper presents an analysis based on the experience in developing the PEN & PAD prototype clinical workstation. The fundamental contention is that the requirements for a medical record must be grounded in its use for patient care. The basic requirement is that it be a faithful record of what clinicians have heard, seen, thought, and done. The other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view. We use the criteria developed to re-examine Weed's Problem Oriented Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support.

Decision Making↗
PubMed1990

[Text, archiving, coding--integration with electronic data processing].

For a successful computer-installation in the medical area you need a staff, which is used to work with computers in the daily routine. We tried with this project to establish the computer in a medical office by doing the whole patient-related writings on a specially tailored software. Most of the daily routine can now be done with the help of the computer. A certain time-saving effect could be achieved, although this was not our first aim. On this base we are now able to solve other problems such as coding, statistics or archiving routines by using our established computer environment.

Archives↗