Entire Medical Record Research Articles

Performance of Fuzzy C-Means (FCM) and Fuzzy Subtractive Clustering (FSC) on Medical Data Imputation

Missing values or incomplete data are frequently encountered in medical records. These issues will be a serious problem if the data must be provided completely for analysis. The research aimed to prove the performance of the Fuzzy Subtractive Clustering (FSC) and Fuzzy C-Means (FCM) methods for solving imputation problems. Both methods were implemented using medical data. It had been conducted using K-Means as a crisp clustering approach for imputation. In the research, fuzzy clustering—a distinct methodology—was applied. The primary research contribution was the suggested fuzzy logic imputation method, which took uncertainty under consideration. The data sample consisted of patients who were at least 40 years old and had a history of hypertension, diabetes, heart disease, stroke, or chronic kidney disease. The test was carried out by taking random portions of data from the entire medical record. The randomization technique used a probability of 10%–50%. The results of the ANOVA test show that the p-value is greater than ∝(=0.05). It means that the imputed value does not differ from the original value, whether implemented in the FSC or FCM method. The algorithm’s performance is evaluated using the Pearson correlation coefficient. According to the t-test results, the FCM method has a higher correlation coefficient than the FSC method. It implies that FCM is superior to FSC.

Implementasi Algoritma Rivest Shamir Adleman (RSA) Untuk Keamanan Data Rekam Medik Penyakit Pasien Rumah Sakit

Medical records are records of the who, what, where, and how of patient care while in hospital. One aspect of the use of medical records is the documentation aspect, namely medical records contain important information that is useful for various parties. Medical records contain data regarding past and present health and contain health professional notes regarding the patient's current condition in the form of physical findings, results of diagnostic and therapeutic procedures and patient responses. Medical record documents belong to doctors, dentists and health service facilities, while the contents of medical records belong to the patient. What can be given, recorded or duplicated by the patient is a summary of the medical record. Patients have the right to know the contents of medical records, however, the entire medical record file can only be held by authorized health/medical records officers and cannot leave the location of the health facility. This aims to maintain medical confidentiality (because medical information can be misused) and prevent medical records from being lost or damaged. To overcome this problem, a computerized system is needed that is able to secure medical record data so that unauthorized parties cannot read it. One technique that can be used to secure medical record data is cryptography. Cryptography comes from Greek which consists of the words kryptos which means hidden and graphia which means something written so that cryptography can be interpreted as something written in secret or hidden.. In applying the Rivest Shamir Adleman (RSA) method in securing medical record data at home Mitra Sejati Medan Hospital, namely by inserting program coding from Shamir Adleman's Rivest method into the programming language used. Next, form a public and private key, then carry out the encryption process for medical record data

317 Clinical Informatics for Head and Cancer Patient Management

OBJECTIVES/GOALS: The management of head and neck cancers is complicated and allows for a variety of disparate approaches from providers. However, data from several hundred or thousands of patients is necessary to decipher the optimal decisions for populations of patients. And prospective trials would take years to accrue and often are financially not possible. METHODS/STUDY POPULATION: Instead, we collated the entire electronic medical record for all patients at our institution treated for head and neck cancers. We employed a variety of clinical informatics and natural language processing to gather text data into large data frames. We found key conclusions in the diagnostic, treatment, and surveillance of our patients. RESULTS/ANTICIPATED RESULTS: First, obtaining post-operative PET/CT changes in management in over one-third of patients, highlighting the utility of optimizing diagnostic imaging. Second, using a newer silicone-based cream instead of just a moisturizer decreased the absolute risk of grade 2+ radiation dermatitis by almost 15%. Lastly, we are deploying novel autosegmentation frameworks to better understand tissue decomposition in the head and neck to identify patients in need of further nutritional support while undergoing radiation therapy. DISCUSSION/SIGNIFICANCE: Collectively, we showcase the value and opportunity of mining oncological data for the improvement of patient care.

Therapy Profile and Drug Use Analysis of Chronic Kidney Disease Patients Hospitalized at Dr. H. M. Ansari Saleh Hospital

Background: Therapy in chronic kidney disease aims to slow down the prognosis of the disease. Objectives: Describe the types of classes and names of most drugs in treating chronic kidney disease patients based on the stage of the disease. As well as analysing the use of renal risk drugs in patients with chronic kidney disease. Material and Methods: This descriptive research will be carried out in May-June 2023. The population of this study was the entire medical record of inpatient chronic kidney disease patients at Ansari Saleh Hospital. Data analysis was performed uni variat for the study of patient characteristics and therapy profiles, while the analysis of the use of renal risk medications refers to the 2019 renal handbook. Results: A total of 51 medical records were analysed. The top five drug classes based on stages 4 and 5 include diuretics, cephalosporin antibiotics, vitamins, trace elements, angiotensin II receptor blockers, and insulin. The top five drugs received by patients based on disease stages 4 and 5 consist of furosemide, ceftriaxone, aminefron®, candesartan, and insulin aspart. Renal risk drugs found in studies include drugs that need dose adjustment, are lisinopril, ramipril, cefixime, cefotaxime, meropenem, levofloxacin, ciprofloxacin, bisoprolol, diltiazem, and simvastatin. At the same time, renal-risk drugs that need to be avoided are hydrochlorothiazide and spironolactone. Conclusions: Furosemide diuretics are the most widely used therapy in stages 4 and 5. Hospitalised chronic kidney disease patients receive some renal risk drugs that, in the literature, need dose adjustment, and some need to be avoided.

Validation of Postsurgical Venous Thromboembolism Diagnoses of Patients Undergoing Lower Limb Orthopedic Surgery in the Danish National Patient Registry.

BackgroundHealthcare databases can be a valuable source of epidemiological research regarding postoperative venous thromboembolism (VTE), ie, deep vein thrombosis (DVT) and pulmonary embolism (PE), following orthopedic procedures, but only if the diagnoses are valid. We examined the validity of VTE diagnosis codes in the Danish National Patient Registry (DNPR) by calculating their positive predictive value (PPV) and negative predictive value (NPV) versus actual medical records.MethodsWe identified patients who had undergone lower limb surgery during the period 2009–2019 at a hospital in the North Denmark Region. Of these, 420 patients had at least one VTE diagnosis registered in the DNPR within 180 days after lower limb surgery. Each patient with a VTE diagnosis was matched with two patients on age and sex, as well as type, location and period of surgery. The entire medical record and diagnostic imaging were reviewed to confirm VTE diagnosis.ResultsThe overall PPVs was 85.2% (95% CI: 81.5–88.5%) for first time VTE diagnosis following lower limb surgery, 82.6% (95% CI: 77.5–82.8%) for DVT, and 90.3% (95% CI: 84.3–94.6%) for PE. We found improvement in PPV during the study period when stratifying for three periods of the whole period. There were no significant differences when stratifying for sex, age, or surgery site. All negative predictive values were higher than 99%. A total of 113 additional VTE diagnoses were registered among 88 VTE patients during follow-up. Only four of the suspected recurrent VTEs were confirmed to be true recurrent VTEs.ConclusionThe VTE diagnosis codes in the DNPR after lower limb orthopedic surgery were highly valid against the actual medical records, and we observed better PPV over recent years.

Security and privacy model of an electronic medical record system

Health information has some unique characteristics. Although it has a lot of personal sensitive information, it should be provided as research data for the development of biomedical science. And, another important characteristic is that the information subject and the information producer are not the same. However, some security scholars have made some errors in applying the security module to the medical information system without considering these characteristics. In this paper, we first analyse the errors. We divide the medical practices performed in the hospital into each process starting from the time the patient visits and registers, and we list the types of medical information used at that stage. Then, we analysed the information subject and information producer for the medical information, set the appropriate encryption key, and designed an encrypted communication protocol for the entire electronic medical record (EMR) data flow. This is a secure and efficient scheme as a hybrid encryption technique that combines a symmetric and an asymmetric encryption technique.

FAKTOR-FAKTOR PENYEBAB KERUSAKAN DOKUMEN REKAM MEDIS RAWAT JALAN DI RUANG PENYIMPANAN RUMAH SAKIT ISLAM SITI KHADIJAH PALEMBANG

The duties, roles and functions of the filing are the filing section serves as a security guard and confidentiality of medical record documents, protects medical record documents from the dangers of physical, chemical, biological damage, assists in the assessment of value for medical records, assists in the implementation of the destruction of medical record forms. This type of research is descriptive research with a qualitative approach. The population in this study was the entire outpatient medical record file in March in the storage room of Siti Khadijah Palembang Islamic Hospital in 2021 and the sample was chosen by using random sampling. The data collection techniques in this study are observations, interviews, documentation and checklists. The study results obtained damage to medical record documents in the storage room RSI Siti Khadijah Palembang by 15%. Intrinsic factors that include the quality of paper, maps, ink, and adhesives are mostly in good condition so it is less likely to be a factor causing damage. Extrinsic factors include dust. It is recommended that rsi Islam Siti Khadijah Palembang add facilities in the storage room, such as installing temperature gauges and humidity temperature in the storage room

Accuracy of the Informant Questionnaire on Cognitive Decline in the Elderly for Detecting Preexisting Dementia in Transient Ischemic Attack and Stroke: A Population-Based Study.

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Potential interventions for an antimicrobial stewardship bundle for Escherichia coli bacteraemia

Escherichia coli is the most commonly identified bacteraemia, and causes a broad spectrum of diseases. The range of clinical conditions associated with E. coli bacteraemia mean that antimicrobial therapy is highly variable. This study aimed to determine the workload, efficiency and potential impact of an antimicrobial stewardship (AMS) bundle approach to E. coli bacteraemia. An observational cohort study of patients with E. coli bacteraemia was performed, and a review of each case's entire medical record was undertaken. A number of AMS interventions were modelled on this cohort to assess their impact on overall days of antimicrobial therapy and time to optimized antimicrobial therapy. In total, 566 episodes of E. coli bacteraemia were identified. A number of AMS interventions were modelled to assess their impact. The strict implementation of guideline-based therapy was found to increase the number of patients receiving ineffective empirical therapy to 38/266 (14.3%) compared with 27/266 (10.2%) patients when w hen non-guideline-adherent therapy was allowed. A scheduled review by an AMS team on day 3 of empirical therapy could lead to a narrower-spectrum intravenous antibiotic in 237/515 (46%) cases, and 386 cases (68.2% of cohort) could have their duration of therapy reduced by a median of 7 days. This study provides detailed description of a large cohort of patients with E. coli bacteraemia. There remains significant variability in empirical treatment, choice of step-down therapy and antimicrobial duration. A significant opportunity exists for AMS programmes to impact the management of E. coli bacteraemia through a bundled approach.

The Accuracy of Disease Code in The Medical Record in Plumbon Public Health Center

The implementation of coding done in the medical record should be done very thoroughly, precisely and accurately according to the diagnostic code that exists in ICD-10. If there is an error in coding, it will have a bad impact on the patient, puskesmas or hospital. But in the fact found in the field there are still problems in the implementation of the accuracy of the encoding of disease diagnosis based on ICD-10. The purpose of this research is to describe the accuracy of disease code in the medical record in Puskesmas Plumbon. The population in this study was the entire quarterly medical record document of year 2020 with a total of 1,098 medical record documents with a total sample of 92 documents using simple random sampling technique. This study was conducted in Plumbon Puskesmas Medical record unit on 20 June 2020. The method used is descriptive with a quantitative approach. The data collection procedures used are by observation and checklist sheet. The population in this study was the entire quarterly medical record document of year 2020 with a total of 1,098 medical record documents with a total sample of 92 documents using simple random sampling technique. This study was conducted in Plumbon Puskesmas Medical record unit on 20 June 2020. The results of the study obtained from 92 samples of medical record documents, the appropriate disease code in accordance with the ICD-10 as much as 39 (42.39%) and improper code of 53 (57.61%). There is still an imprecision of unsuitable disease code due to coding officers that do not include the 4th character. It is best to need a fixed procedure in accordance with WHO provisions for coding the disease to make the koder more thorough in determining the disease code.

Description Of Completeness Of Sheeting Assessment Sheet In Hospital Sumber Kasih Cirebon City

Incompleteness in filling out the inpatient pain assessment sheet will have an impact on the discontinuity of information and will affect the quality of health service facilities. The purpose of this study was conducted to determine the completeness of the Inpatient Pain Assessment Sheet at Sumber Kasih Hospital, Cirebon City.This type of research is quantitative descriptive. The population is the entire medical record document from January to March in 2020 with a sample of 99 medical record documents. This research instrument uses observation sheets. The results of this study indicate that there are 1 (1%) medical record documents that are completely filled and 98 (99%) incomplete medical record documents on the pain assessment sheet form. As for the conclusion in this research the completeness of the study sheet of pain in Sumber Kasih Cirebon City Hospital 1 while the incomplete study sheet of 99. And also the advice in this research is advice for hospitals should be evaluated to maintain the quality of health services improve the performance of medical record officers in the Sumber Kasih Cirebon City Hospital.

Diagnostic performances of lung ultrasound associated with inferior vena cava assessment for the diagnosis of acute heart failure in elderly emergency patients: a diagnostic study.

Few studies are looking at the usefulness of lung ultrasound combined with inferior vena cava (ultrasound strategy) in the particularly challenging diagnosis of acute heart failure (AHF) in elderly dyspneic patients attending the emergency department (ED). This was a prospective diagnostic study conducted in two French EDs from December 2015 to March 2019, aimed to determine the accuracy of an ultrasound strategy for the diagnosis of AHF in the elderly. Patients aged 65 and older referred to the ED for dyspnea were screened for inclusion. An emergency physician, blinded to the first findings, performed chest ultrasound, and assessment of inferior vena cava (ultrasound strategy). The primary endpoint was a final diagnosis of AHF, adjudicated by two independent experts after reviewing the entire medical record. The sensitivity and specificity of ultrasound and standard strategies were calculated. A total of 116 patients were included, mean age 84 years (SD 9). Among them, there were 76 (66%) cases of AHF and 51 (44%) cases of pneumonia. The ultrasound work up had a sensitivity of 82% [95% confidence interval (CI), 71-90] and a specificity of 68% (95% CI, 51-90] for AHF. The standard strategy had a sensitivity of 92% (95% CI, 84-97) and a specificity of 53% (95% CI, (36-68). In this prospective study, there was no statistically significant difference between point-of-care ultrasound and a combination of clinical, radiographic, and biological findings for the diagnosis of acute heart failure.

High incidence of varicocele among young men in Public Police Hospital Denpasar, Bali, Indonesia: a descriptive study

Background: Varicocele is a progressive disease which possibly starts from puberty. When left untreated, it could progress and causes complications such as infertility. Determination on the representative national incidence and characteristic of varicocele has been a hard challenge due to the lack of data on varicocele epidemiological studies, especially in Bali. This study aims to know the characteristic of varicocele patients undergoing varicocelectomy in Bhayangkara Denpasar Hospital from January 2017 to December 2018. Methods: This research is a descriptive retrospective study with cross sectional approach. The population of the study consists of patients who were diagnosed with varicocele and underwent varicocelectomy in Bhayangkara Denpasar Hospital from January 2017 to December 2018. Total sampling method was used. Research data were retrieved by taking the patient’s entire medical record with varicocele in Bhayangkara Denpasar Hospital from January 2017 to December 2018.Results: Ninty five samples were diagnosed with varicocele and underwent varicocelectomy. The highest percentage among age groups is 15 to 24 years (89.5%), with normal stature (94%), normal weight (86%), asymptomatic (90.5%), left unilateral varicocele (86.%), grade III varicocele (82,1%) and without comorbid (93.8%). The samples underwent varicocelectomy with Ivanissevich procedure (72.8%), operation time of ≤ 60 minutes (95.8%) and length of stay of ≤ 2 days (95.8%).Conclusion: The high incidence of varicocele in young adulthood is due to a majority of the samples being young police recruitment participants who were accidentally diagnosed during general medical check-up. Early screening on varicocele in the age group of 15 to 24 years is recommended to consider the need of sperm analysis examination and further deciding on the treatment options. One of the options is surgery.

PERBEDAAN RERATA FAKTOR HEMOSTASIS PADA PREEKLAMPSIA BERAT DAN EKLAMPSIA

Objective : To find the difference in mean hemostatic factors in severe preeclampsia and eclampsia. Method : The study was analytic descriptive using a cross sectional study design by looking at the subject's Medical Record according to the time and place of research. The sample is the entire medical record of pregnant women who suffer from preeclampsia and eclampsia in the obstetric and gynecology departments of Dr. M. Djamil Padang Hospital in the period 15 January 2016 to 31 December 2017. The assessment was in the form of assessed platelet levels, PT, APTT and D-Dimer. Samples were taken from populations that met the inclusion criteria and did not have exclusion criteria. Sampling using consecutive sampling techniques taken from the Medical Record Dr. M.Djamil Padang. Statistical analysis to assess significance using the T-Test. Result : The severity the condition of pregnancy the lower the platelet mean and PT. Significant differences were obtained between platelets in PEB and eclampsia (p> 0.05). The mean PT, APTT and D-Dimer showed no significant differences in pregnancy conditions. Statistical test with T-Test did not show significant differences in mean PT, APTT, and D-dimer between eclampsia and PEB (p> 0.05). Conclusion : There were significant differences in mean in platelets, whereas in PT, APTT, and D-dimers in PEB and eclampsia there were no significant differences. Keywords: Pregnancy, severe preeclampsia, eclampsia, platelets, PT, APTT, D-Dimer.

PERBEDAAN RERATA FAKTOR HEMOSTASIS PADA PREEKLAMPSIA BERAT DAN EKLAMPSIA

Objective : To find the difference in mean hemostatic factors in severe preeclampsia and eclampsia.Method : The study was analytic descriptive using a cross sectional study design by looking at the subject's Medical Record according to the time and place of research. The sample is the entire medical record of pregnant women who suffer from preeclampsia and eclampsia in the obstetric and gynecology departments of Dr. M. Djamil Padang Hospital in the period 15 January 2016 to 31 December 2017. The assessment was in the form of assessed platelet levels, PT, APTT and D-Dimer. Samples were taken from populations that met the inclusion criteria and did not have exclusion criteria. Sampling using consecutive sampling techniques taken from the Medical Record Dr. M.Djamil Padang. Statistical analysis to assess significance using the T-Test.Result : The severity the condition of pregnancy the lower the platelet mean and PT. Significant differences were obtained between platelets in PEB and eclampsia (p> 0.05). The mean PT, APTT and D-Dimer showed no significant differences in pregnancy conditions. Statistical test with T-Test did not show significant differences in mean PT, APTT, and D-dimer between eclampsia and PEB (p> 0.05).Conclusion : There were significant differences in mean in platelets, whereas in PT, APTT, and D-dimers in PEB and eclampsia there were no significant differences.Keywords: Pregnancy, severe preeclampsia, eclampsia, platelets, PT, APTT, D-Dimer.

Completeness of informed consent in supporting national standard accreditation of patient and family rights 5 hospitals at Ropanasuri surgical special hospital in Padang

Background: Completeness of informed consent is one indicator in supporting the accreditation of national hospital standards through the assessment of patient and family rights (PFR) assessment standards 5. In the health service process, informed consent can also be used as evidence and has a strong legal value in the form of a sheet of paper containing the doctor’s explanation about the diagnosis of the disease and the actions that will be performed on the patient.Methods: This research uses descriptive method with a qualitative approach. The population used was the entire patient medical record file in 2018, which was 3.093 medical record files. Sampling was done by random sampling using a formula according to Notoatmodjo for the calculation of the number of samples and obtained 355 files of medical records. Data processing using Microsoft Excel computer programs. For observing the completeness of the standard rights of patients and families using national standards for hospital accreditation.Results: Based on the analysis of 355 medical record files at Ropanasuri specialty hospital it is known that 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%. The results showed the greatest incompleteness found in filling the informed consent items of witness signatures of 2.81%, providing information on the completeness of filling the doctor's identity by 2.54% and the name of the witness 1.70% on filling the authentication.Conclusions: 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%.

Human versus machine in medicine: can scientific literature answer the question?

Human versus machine in medicine: can scientific literature answer the question?

Patient engagement or information overload: patient and physician views on sharing the medical record in the acute setting

Background: Patient and professional views about the impact of providing full real-time access to the medical record in the in-hospital setting are unknown.Methods: Likert-scale and free-text validated questionnaire survey of physicians and patients from acute medical units in two hospitals. The questionnaire explored recent experiences; views on the formation of trust, and views on sharing either the entire medical record or a summary.Results: Two-hundred and forty-eight patient questionnaires (62% response rate) and 32 physician questionnaires (21% response rate) were returned. Twenty-seven per cent of patients did not recall being told their diagnosis. Doctors and patients differed on what practices that they believed built trust.Eighty-one per cent of patients supported the idea of having access to the full medical record (for empowerment; the right to information about oneself; as an aide-memoire for discussion). Doctors feared it might provoke anxiety and change the nature of what was written. A written lay summary record was preferred by doctors and patients.Conclusions: The current system of providing information verbally to patients is inadequate. Patients want more information and are less concerned than physicians about potential negative effects of real-time access to their records. Patient access to medical records (in both full and summary forms) should be evaluated.

Adult vaginal foreign body misdiagnosed as cervical cancer: a case report and literature review

Objective: By describing a case of vaginal foreign body misdiagnosed as cervical cancer in a female of reproductive age, gynecologists should be warned to be careful in the process of diagnosis and treatment. Materials and Methods: Retrospective review of the entire medical record of a female Tibetan patient who was misdiagnosed with cervical cancer. Results: The patient received hysteroscopy under general anesthesia. Two white plastic bottles for Yunnan Baiyao were found after separating the vaginal stenosis and after removing the vaginal foreign bodies, a smooth and complete cervix was found. Conclusion: This study suggests that gynecologists should be careful with physical examination, as they should ask patients more questions, and not limit their clinical thinking to common diseases, and thereby reducing misdiagnosis to the lowest possible.

Semi-supervised estimation of covariance with application to phenome-wide association studies with electronic medical records data.

Electronic medical records data are valuable resources for discovery research. They contain detailed phenotypic information on individual patients, opening opportunities for simultaneously studying multiple phenotypes. A useful tool for such simultaneous assessment is the phenome-wide association study, which relates a genomic or biological marker of interest to a wide spectrum of disease phenotypes, typically defined by the diagnostic billing codes. One challenge arises when the biomarker of interest is expensive to measure on the entire electronic medical record cohort. Performing phenome-wide association study based on supervised estimation using only subjects who have marker measurements may yield limited power. In this paper, we focus on the setting where the marker is measured on a small fraction of the patients while a few surrogate markers such as historical measurements of the biomarker are available on a large number of patients. We propose an efficient semi-supervised estimation procedure to estimate the covariance between the biomarker and the billing code, leveraging the surrogate marker information. We employ surrogate marker values to impute the missing outcome via a two-step semi-non-parametric approach and demonstrate that our proposed estimator is always more efficient than the supervised counterpart without requiring the imputation model to be correct. We illustrate the proposed procedure by assessing the association between the C-reactive protein and some inflammatory diseases with an electronic medical record study of inflammatory bowel disease performed with the Partners HealthCare electronic medical record database where C-reactive protein was only measured for a small fraction of the patients due to budget constraints.