Abstract
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standard IM.7.4 mandates that the patient's medical record contain a summary list of prior hospital activity (diagnoses, procedures, drug allergies and medications). In compliance with standards set by JCAHO, members of Quality Management, Health Information, Ancillary Departments, Information Management, and Medical Staff at Long Beach Community Medical Center in California devised an automated Patient Summary Record (PSR) that far exceeds the current regulations using the existing IBM AS-400 systems. This was accomplished without the addition of new hardware or software. The format has proven to be an important communication tool, which delivers critical patient information in a timely fashion. An additional benefit of the PSR is that it compensates for the many patients who are poor historians of their medical past by providing physicians and other health care providers with essential medical history. Utilized across all hospital disciplines, the PSR has proven to be a life-saving instrument, especially in the emergency department, where having a patient's medical history immediately on arrival can be crucial to the eventual treatment outcome.
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