Accuracy Of Medical Record Research Articles

Bibliometric Analysis of Factors Affecting Performance and Completeness of Electronic Medical Records (EMR) in Primary Health Services

ABSTRACT Electronic Medical Records (EMR) completeness and accuracy are fundamental to effective patient care, clinical decision-making, and overall healthcare management. In recent years, there has been increasing attention to improving EMR documentation by healthcare professionals to improve data quality and patient care outcomes. This bibliometric study aimed to explore the trends, research focus, and gaps in the literature regarding EMR completeness from 2019 to 2024. The study used Publish or Perish software to collect data from Google Scholar with specific keywords such as Performance, Factors, Electronic Medical Record (EMR), EMR Completeness, Primary Healthcare, Filling, Documentation, and Medical Record Accuracy. The analysis included the 30 highest ranked journals. In addition, VOS Viewer was used for network visualization, overlay, and density to analyze thematic linkages and identify potential research gaps. Bibliometric analysis showed that Indonesia, the United States, and Ethiopia were the main contributors in EMR-related publications. Frequent themes such as data completeness, quality, and accuracy, emphasize their crucial role in the EMR research field. These findings emphasize the importance of continuously improving EMR data completeness and accuracy, which are critical for reliable clinical decision making and effective healthcare delivery. Future research should focus on developing methodologies to improve data quality and integration of EMR systems with other health information systems. In addition, exploration of policy and regulatory implications related to EMR completeness may provide valuable insights for healthcare practice. Keywords: EMR Completeness, Data Quality, Bibliometric Analysis, Health Documentation, VOS Viewer.

Faktor yang berhubungan dengan Catatan Keperawatan Dokumen Rekam Medis Rawat Inap di Rumah Sakit H. Adam Malik Medan

<p><em>Nursing records are one of the most important aspects of the role of health care providers because they are evidence of the implementation of nursing care. Nursing documentation confirms that the legal and ethical responsibilities of nurses to patients have been fulfilled, and patients receive quality nursing care. Quality medical records are related to the completeness of medical record entries, accuracy, accuracy of medical record records, timeliness and fulfillment of legal aspects. </em><em>The purpose of this study was to determine factors related to nursing records of inpatient medical records at H. Adam Malik Hospital Medan This study uses an analytical survey method with a cross sectional approach. The population in this study were all 50 inpatient nurses and 50 samples were taken using a total sampling technique. Data analysis used univariate, bivariate and multivariate analysis with data analysis using logistic regression test. The results of the chi-square test analysis show that the p-value of each variable includes workload, p-value = 0.022, performance p-value = 0.018 and supervision p-value = 0.046. The conclusion of this study is that there is a relationship between workload, performance and supervision with inpatient medical records. </em><em>It is expected to carry out regular and periodic supervision of each implementing nurse in the inpatient room, in this case the head of the room needs to plan direct and indirect supervision activities on a regular basis and is also involved in the implementation of nursing records</em></p>

What do we know about the risks of developing dementia after traumatic brain injury?

Traumatic brain injury (TBI) is a risk factor for the later development of dementia, but although the evidence dates back to the early 20th century, the nature of any association and its mechanistic pathways remain unclear. There has been greater focus on this subject over recent years, in part because of increasing reports around sports related TBIs, especially in the USA. Differences in research methods and clinical sampling remain the primary reason for the variable findings, although there is clearly increased prevalence of neurodegenerative disorders in general. Duration of follow up, definition of both TBI and dementia, and differences in the extent to which other dementia risk factors are controlled, as well as concerns about medical record accuracy are all issues yet to be resolved in TBI research, as is an absence pathological evidence. In addition, TBI has been reported to initiate a cascade of pathological processes related to several neurodegenerative disorders, and as such, it is likely that the risks vary between individuals. Given the evidence that dementia risk may increase with injury severity and frequency, a detailed account of age and type of injury, as well as lifetime TBI exposure is essential to document in future studies, and further longitudinal research with biomarker assessments are needed.

Assessment of Patient Medication Adherence, Medical Record Accuracy, and Medication Blood Concentrations for Prescription and Over-the-Counter Medications

ImportanceInaccurate medication records and poor medication adherence result in incomplete knowledge of therapy for patients.ObjectiveTo study accuracy of medical records and patient adherence by measuring blood concentrations of medications.Design, Setting, and ParticipantsThis cross-sectional study validated a serum-based liquid chromatography–tandem mass spectrometry assay to simultaneously quantify 263 medications used for acute and chronic conditions. The assay panel was applied to 3 clinical patient cohorts: residual serum from 1000 randomly selected samples sent for routine clinical chemistry testing between April 8 and October 6, 2015 (residuals cohort), 50 prospectively enrolled patients in a gastroenterology clinic between March 1 and March 15, 2016, who were prescribed more than 5 medications (gastroenterology care cohort), and a convenience cohort of 296 patients with hypertension who sought care in an emergency department (ED care cohort) between July 1, 2012, and April 25, 2013. Integrated data analysis of the cohorts was performed from August 22 to November 29, 2017.Main Outcomes and MeasuresMedication serum concentrations, electronic health record medication lists, and predicted drug interactions.ResultsOf the 1346 total samples, 1000 came from the residuals cohort (640 women and 360 men; median age, 60 years [interquartile range (IQR), 44-71 years]), 50 from the gastroenterology care cohort (30 women and 20 men; median age, 66 years [IQR, 62-70 years]), and 296 from the ED care cohort (160 women and 136 men; median age, 59 years [IQR, 52-66 years]). Median medication adherence, defined as the subset of detected medications from the prescription record, was 83% (IQR, 50%-100%) in the residuals cohort, 100% (IQR, 84%-100%) in the gastroenterology care cohort, and 78% (IQR, 57%-100%) in the ED care cohort. Patients adherent to 1 medication were more often adherent to other medications. Among patients prescribed 3 medications or more, there were no significant associations between medication adherence and sex or number of prescribed medications, and there was a modest association between adherence and age. By comparing detected vs prescribed medications, we detected a median of 0 (IQR, 0-2) medications per patient that were not listed in the electronic health record in the residuals cohort, 1 (IQR, 0-2) medication per patient that was not listed in the electronic health record in the gastroenterology care cohort, and 1 (IQR, 0-2) medication per patient that was not listed in the electronic health record in the ED care cohort. A total of 435 patients (43.5%) in the residuals cohort had no discrepancy between the electronic health record and detected medication lists, 22 patients (44.0%) in the gastroenterology care cohort had no discrepancy between the electronic health record and detected medication lists, and 41 patients (13.9%) in the ED care cohort had no discrepancy between the electronic health record and detected medication lists. Half of adverse drug reaction alerts occurred among medications detected without prescription.Conclusions and RelevanceComprehensive medication monitoring offers promise to improve adherence, the accuracy of medical records, and the safety for patients with polypharmacy.

Patient Engagement In Health Care Safety: An Overview Of Mixed-Quality Evidence.

Patients and caregivers play a central role in health care safety in the hospital, ambulatory care setting, and community. Despite this, interventions to promote patient engagement in safety are still underexplored. We conducted an overview of review articles on patient engagement interventions in safety to examine the current state of the evidence. Of the 2,795 references we evaluated, 52 articles met our full-text inclusion criteria for synthesis in 2018. We identified robust evidence supporting patients' self-management of anticoagulation medications and mixed-quality evidence supporting patient engagement in medication and chronic disease self-management, adverse event reporting, and medical record accuracy. Promising modes of patient engagement in safety, such as anticoagulation management and patient portal access, are not widely implemented. We discuss major implementation priorities and propose directions for future research and policy to enhance patient partnership within safety efforts.

Medication adherence, medical record accuracy, and medication exposure in real-world patients using comprehensive medication monitoring.

BackgroundPoor adherence to medication regimens and medical record inconsistencies result in incomplete knowledge of medication therapy in polypharmacy patients. By quantitatively identifying medications in the blood of patients and reconciling detected medications with the medical record, we have defined the severity of this knowledge gap and created a path toward optimizing medication therapy.Methods and findingsWe validated a liquid chromatography-tandem mass spectrometry assay to detect and/or quantify 38 medications across a broad range of chronic diseases to obtain a comprehensive survey of patient adherence, medical record accuracy, and exposure variability in two patient populations. In a retrospectively tested 821-patient cohort representing U.S. adults, we found that 46% of medications assessed were detected in patients as prescribed in the medical record. Of the remaining medications, 23% were detected, but not listed in the medical record while 30% were prescribed to patients, but not detected in blood. To determine how often each detected medication fell within literature-derived reference ranges when taken as prescribed, we prospectively enrolled a cohort of 151 treatment-regimen adherent patients. In this cohort, we found that 53% of medications that were taken as prescribed, as determined using patient self-reporting, were not within the blood reference range. Of the medications not in range, 83% were below and 17% above the lower and upper range limits, respectively. Only 32% of out-of-range medications could be attributed to short oral half-lives, leaving extensive exposure variability to result from patient behavior, undefined drug interactions, genetics, and other characteristics that can affect medication exposure.ConclusionsThis is the first study to assess compliance, medical record accuracy, and exposure as determinants of real-world treatment and response. Variation in medication detection and exposure is greater than previously demonstrated, illustrating the scope of current therapy issues and opening avenues that warrant further investigation to optimize medication therapy.

ANALISIS MUTU LAYANAN UNIT REKAM MEDIS BERDASARKAN KEPUASAN PELANGGAN INTERNAL DENGAN MENGGUNAKAN METODE SERVICE QUALITY DAN QUALITY FUNCTION DEPLOYMENT DI RSD KALISAT JEMBER

ABSTRACT URM (Unit Rekam Medis) is one the healthy facilities headed by medical record chief. The head of medical record has the authority to manage everything related to URM. RSD Kalisat is one of state hospitals in Jember which has a vision as the pioneer hospital with the best quality and reachable for everyone. The quality of URM plays important role to support the quality of the hospital. One of the ways to measure the quality of URM is by using quality and quality function deployment method. This research is aimed to get the information about the quality service of medical record based on internal patient satisfactory in medical record at RSD kalisat by using quality and Quality Function Deployment (QFD). From the result of the analysis, we have conclusion as the following; 1) there are some variables influence the quality servicen of five dimension, such as: the strategic place of URM building from the ambulatory care,the strategic place of URM building from the long term care, thestorage room of medical record equipment, the number of employments, communication service, the repidity of medical record file, the accuracy of medical record, the appropriateness of the information, medical record employee readiness, the accuracy if taking off the medical record file, the employee friendlines, the safety of medical record, the attitude of the employee dealing with the nurse. 2) The satisfactory of nuse toward to URM service is good enuogh. 3) The expecatation of ”communication” with high score 4,60 and the expectation of ”the distance between URM building from ambulatory care” with the lowest 4,26. 4) The priority related to nurse necessary needed to focus by URM dealing with medical record employee readiness which has normalize raw weight value 0,0588. 5) The action priority for URM employee is ”internal and external training” which has the higher normalized contribution normalized contribution value0,2144 Keywords: Quality, Quality Service, Quality Function Deployment, Medical Record

How patients can improve the accuracy of their medical records.

Objectives:Assess (1) if patients can improve their medical records’ accuracy if effectively engaged using a networked Personal Health Record; (2) workflow efficiency and reliability for receiving and processing patient feedback; and (3) patient feedback’s impact on medical record accuracy.Background:Improving medical record’ accuracy and associated challenges have been documented extensively. Providing patients with useful access to their records through information technology gives them new opportunities to improve their records’ accuracy and completeness. A new approach supporting online contributions to their medication lists by patients of Geisinger Health Systems, an online patient-engagement advocate, revealed this can be done successfully.In late 2011, Geisinger launched an online process for patients to provide electronic feedback on their medication lists’ accuracy before a doctor visit. Patient feedback was routed to a Geisinger pharmacist, who reviewed it and followed up with the patient before changing the medication list shared by the patient and the clinicians.Methods:The evaluation employed mixed methods and consisted of patient focus groups (users, nonusers, and partial users of the feedback form), semi structured interviews with providers and pharmacists, user observations with patients, and quantitative analysis of patient feedback data and pharmacists’ medication reconciliation logs.Findings/Discussion:(1) Patients were eager to provide feedback on their medications and saw numerous advantages. Thirty percent of patient feedback forms (457 of 1,500) were completed and submitted to Geisinger. Patients requested changes to the shared medication lists in 89 percent of cases (369 of 414 forms). These included frequency—or dosage changes to existing prescriptions and requests for new medications (prescriptions and over-the counter). (2) Patients provided useful and accurate online feedback. In a subsample of 107 forms, pharmacists responded positively to 68 percent of patient requests for medication list changes. (3) Processing patient feedback will requires both software algorithms and human interpretation. For the 107 forms subsample, pharmacists accepted patient input in 51 percent of cases where they could not contact the patient. Where the patient was contacted, they accepted feedback from 68 percent. This suggests there may be opportunities to automate feedback filtering and processing for more efficient (and larger scale) medication-list optimization. (4) A supportive overall e-health environment makes acceptance of an online patient feedback system more likely. Review of Geisinger usage data showed patients who completed the medication feedback form had previously accessed MyGeisinger 2.3 times as often as the average patient and initiated secure messages with a clinician 1.35 times as often as patients not involved in the pilot.Conclusions:Patient feedback, placed in a useful workflow, can improve medical record accuracy. Electronic health record (EHR) vendors and developers need to build appropriate capabilities into applications. Continued research and development is needed for enabling health care organizations to elicit and process patient information most effectively.

How accurate are medical record data in Afghanistan's maternal health facilities? An observational validity study

ObjectivesImprovement activities, surveillance and research in maternal and neonatal health in Afghanistan rely heavily on medical record data. This study investigates accuracy in delivery care records from three hospitals across...

Improving the Quality of Nursing Home Care and Medical-Record Accuracy With Direct Observational Technologies

Nursing home medical-record documentation of daily-care occurrence may be inaccurate, and information is not documented about important quality-of-life domains. The inadequacy of medical record data creates a barrier to improving care quality, because it supports an illusion of care consistent with regulations, which reduces the motivation and ability of providers to identify areas for improvement. Observational protocols designed for use by survey and quality-assurance staff can provide the independent information necessary for improving both medical record accuracy and residents' quality of life. Unfortunately, observational protocols currently used in survey and quality-assurance activities are not designed in a manner that is consistent with the scientific principles that guide observational measurement. The purpose of this article is to describe the steps to develop a standardized and scientifically defensible observational system to assess nursing home care quality.

The Use of a Human Patient Simulator in the Evaluation of and Development of a Remedial Prescription for an Anesthesiologist with Lapsed Medical Skills

The New York State Society of Anesthesiologists’ Committee on Continuing Medical Education and Remediation has been charged by the Office of Professional Medical Conduct of the New York State Department of Health to develop a remediation program for individuals ordered into retraining. We describe the development of an anesthesiology-specific evaluation to identify areas of deficiency to both determine a candidate’s suitability, as well as to facilitate the creation of an appropriate prescription for retraining. A human patient simulator was used to aid in the gathering of information during the evaluation process. Specifically, the use of simulation allowed the exploration of a candidate’s preparation, approach to clinical situations, technical abilities, response to clinical problems, ability to problem solve, and accuracy of medical record keeping. Human patient simulation should be considered a valuable tool in the process of evaluating physicians with lapsed medical skills.

The use of a human patient simulator in the evaluation of and development of a remedial prescription for an anesthesiologist with lapsed medical skills.

The New York State Society of Anesthesiologists' Committee on Continuing Medical Education and Remediation has been charged by the Office of Professional Medical Conduct of the New York State Department of Health to develop a remediation program for individuals ordered into retraining. We describe the development of an anesthesiology-specific evaluation to identify areas of deficiency to both determine a candidate's suitability, as well as to facilitate the creation of an appropriate prescription for retraining. A human patient simulator was used to aid in the gathering of information during the evaluation process. Specifically, the use of simulation allowed the exploration of a candidate's preparation, approach to clinical situations, technical abilities, response to clinical problems, ability to problem solve, and accuracy of medical record keeping. Human patient simulation should be considered a valuable tool in the process of evaluating physicians with lapsed medical skills.

Accuracy of Medical Records in Documenting Drug Therapy in Routine Surgical Procedures

The accuracy of medical records with regard to routine antibiotic prophylaxis was evaluated at a Brazilian hospital. Data were obtained from 99 patients undergoing surgical procedures using two methods: (1) from a specific form filled out by the anesthetist immediately after surgery and (2) from the medical record after approximately 1 month. Data collected in the operating suite were used as our “gold standard” of what actually happened. The likelihood of antibiotic prophylaxis having been used according to the guideline if the medication administration record indicated that it had been was 83%. In cases in which the record reviewer observed that the antibiotic prophylaxis had not been used according to the guideline, the likelihood of patients having, in fact, received the drug correctly was 11%. In conclusion, the medical records were generally accurate.

Optimizing Hospital Reimbursement Through Physician Awareness: A Step Toward Better Patient Care

We instituted a training program to improve the overall accuracy of medical record coding through greater physician awareness to enhance hospital reimbursement and maintain quality patient care. A physician-targeted course reviewed the prospective payment system, diagnosis-related group guidelines, ambulatory surgery reimbursement, and the relationship between accurate physician documentation and medical record coding. Annual increases in charges from prospective surgical case assignment, proper conversion of outpatient to inpatient status, and more accurate coding of inpatient comorbidities and complications led to an estimated increase in hospital charges of $1.6 million.

46. The Accuracy of Medical Records and Police Reports in Determining Motor Vehicle Crash Characteristics

Objective: To determine the accuracy of ambulance (AR), emergency department (EDR) and police (PR) records in describing motor vehicle crash (MVC) characteristics when compared to a standard - an in-depth motor vehicle crash investigation record (CIR).Methods: Fifty-six MVC patients transported to a suburban, university hospital emergency department via ambulance and included in a crash investigation were identified. The time period was January 1993 through December 1995. Data sources were the AR, EDR, PR and CIR. The CIR was abstracted to a standard form. The other data sources were abstracted to a standard form using a retrospective, blinded review. Variables included occupant position, restraint use, air bag deployment, type of impact, ejection, and external cause of injury code. Accuracy was measured by determining percent agreement and Kappa for each data source compared to the CIR.Results: Forty-six cases (82%) had one or more episodes of discordance. The mean percent agreement for the sources studied was AR 0.813, EDR 0.893 and PR 0.932. Mean values for Kappa were AR 0.712, EDR 0.831 and PR 0.885. Among variables, restraint use was determined with the least accuracy with means for percent agreement and Kappa of 0.792 and 0.674, respectively. For the AR, discordance was due to missing information almost 50% of the time.