Medical Record Information Research Articles

Accountability of Hospitals for Medicare Beneficiaries' Postacute Care Discharge Disposition.

Accountability of Hospitals for Medicare Beneficiaries' Postacute Care Discharge Disposition.

Construction of Dynamic Medical Information System for Digital Hospital Environments

The distribution of healthcare information via cloud-based hospital information systems has been increasing in recent years. Because these systems can disseminate sensitive healthcare information to various smart devices, their security approaches must be carefully studied. In addition, research is required to ensure that patients are being properly notified about changes in their medical treatments. Therefore, in this paper, we propose a dynamic medical information system for digital hospital environments. For this purpose, we design a system that can securely distribute existing digital hospital data, including medical images and patient record information. In order to classify the providing services, we divide them into two types--synchronization and security. We suggest a dynamic authentication method to access medical information. Moreover, the proposed system provides Digital Imaging and Communications in Medicine (DICOM) file synchronization between system environments. We confirm the usefulness of the application based on experimental results.

Trends in Male and Female Genital Warts Among Adolescents in a Safety-Net Health Care System 2004-2013: Correlation With Introduction of Female and Male Human Papillomavirus Vaccination.

Human papillomavirus (HPV) vaccination remains underused in the United States, and few population-level studies on effectiveness exist. We examined trends in rates of genital warts diagnoses and HPV vaccination rates (defined as receipt of 1 or more vaccine doses) among low-income and minority adolescents between 2004 and 2013. Data were obtained from a database containing de-identified medical record information including all outpatient visits to an urban medical center and 6 affiliated community health centers. International Classification of Diseases, Ninth Revision codes were used to determine genital warts diagnoses. We estimated annual rates of genital warts for each period for females and males using an interrupted time-series Poisson regression model. As HPV vaccination rates in low-income, minority adolescents rose from 0% to 59% (females) and 0 to 41% (males) between 2004 and 2013, genital warts rates decreased from 3.5% (females) and 3.6% (males) to 1.5% (females) and 2.9% (males). Rates of genital warts decreased significantly for both females and males from the prevaccination to the postvaccination periods (P < 0.05 for both comparisons). Genital warts rates for males began to decrease after the introduction of female vaccination and continued to decrease after male vaccination was introduced. Introduction of HPV vaccination correlated with lower rates of genital warts among a cohort of low-income and minority adolescents. Rates of genital warts began to decrease in females and males following the introduction of female vaccination and continued to fall after the introduction of male vaccination, indicating that male vaccination may confer additional benefit to both males and females over herd immunity alone, especially when vaccination rates are suboptimal.

Evaluation of Posttreatment Follow-Up of Patients With Prostate Cancer Relative to the American College of Radiology's Appropriateness Criteria.

The American College of Radiology (ACR) Appropriateness Criteria panel has recommended that patients with prostate cancer who have received treatment undergo imaging only after suspected cancer recurrence. We examined whether local physicians followed this recommendation and what types of imaging examinations were ordered in a cohort of patients with local prostate cancer. The Rochester Epidemiology Project, a research consortium that collects, links, and stores medical record information of Olmsted County, Minnesota, residents, was used to capture the complete medical history of treated patients with prostate cancer from 2000 through 2011. Clinical information and imaging examinations performed were retrieved by chart review. Suspected recurrence was defined as treatment-specific prostate-specific antigen level elevations, bone pain, or abnormal digital rectal examination findings. Of the 670 treated patients with prostate cancer who were included in the final analysis, 129 (19%) underwent posttreatment imaging. After excluding imaging related to retreatment or another cancer, 13 patients (i.e., 2% of the entire cohort and 10% of imaged patients) underwent imaging in the absence of suspected recurrence. A total of 90 patients (70% of imaged patients) underwent imaging after suspected recurrence. Of these 90 patients, 62 (69%) underwent a bone scan as their first imaging modality either alone or in combination with other imaging modalities. Of the providers who ordered a bone scan first, 27% were urologists, 23% were radiation oncologists, and 24% were primary care physicians. Most patients in this study did not undergo imaging in the absence of suspected recurrence. Various types of imaging examinations were ordered for patients with suspected recurrence.

The effect of labour induction on the risk of caesarean delivery: using propensity scores to control confounding by indication.

To use propensity score methods to control for confounding by indication in the association between labour induction and caesarean delivery. Cross-sectional analysis of administrative hospital discharge data supplemented by medical record information. Fourteen US member hospitals of the National Perinatal Information Center. A cohort of 166559 singleton liveborn deliveries in the period 2007-2012. We used propensity scores (PSs) to balance 83 covariates between induced and non-induced women, and compared estimates with traditional covariate adjustment. We estimated PSs for labour induction versus expectant management of pregnancy each week from 34 to 42weeks of gestation. We estimated risk ratios (RRs) for the association between labour induction and primary caesarean delivery from models with no adjustment, traditional adjustment of five covariates, matched PS, and adjustment for continuous PS. Caesarean delivery in current or subsequent week of gestation. In crude models labour induction increased the risk of caesarean delivery in all weeks (RR1.06-1.52), excepting 39weeks of gestation (RR0.89). After matching on PS, the analysis showed a significantly decreased risk of caesarean delivery with labour induction during weeks35-39 (RR0.77-0.92), and a significantly elevated risk at weeks40 (RR1.22) and 41 (RR1.39). Traditional covariate and PS adjustment resulted in RRs between those from crude and PS-matched models. There is evidence of considerable confounding by indication in the association of labour induction and caesarean delivery, particularly for preterm deliveries. Using PS methods, we found a reduced risk of caesarean delivery with labour induction before 40weeks of gestation, and an elevated risk for weeks40-42. With confounding adjustment, labour induction does not increase the risk of caesarean at 34-39weeks of gestation.

Health Care Utilization by Body Mass Index in a Pediatric Population

ObjectiveWe tested the hypothesis that the frequency of emergency department (ED) visits, outpatient clinic visits, and hospitalizations were higher among children with higher body mass index (BMI) categories, even after controlling for demographics, socioeconomic status, and presence of other chronic medical conditions. MethodsWe obtained electronic height, weight, and utilization data for all residents of Olmsted County, Minnesota, aged 2 to 18 years on January 1, 2005 (n = 34,335), and calculated baseline BMI (kg/m2). At least 1 BMI measurement and permission to use medical record information was available for 19,771 children (58%); 19,528 with follow-up comprised the final cohort. BMIs were categorized into underweight/healthy weight (<85th percentile), overweight (85th to <95th percentile), and obese (≥95th percentile). Negative binomial models were used to compare the rate of utilization across BMI categories. Multivariable models were used to adjust for the effects of age, race, sex, socioeconomic status, and chronic medical conditions. ResultsCompared to children with BMI <85th percentile, overweight and obese status were associated with increased ED visits (adjusted incident rate ratio [IRR] 1.16, 95% confidence interval [CI] 1.10, 1.23; and IRR 1.27, 95% CI 1.19, 1.35, respectively; P for trend <.0001), and outpatient clinic visits (IRR 1.05, 95% CI 1.02, 1.08; and IRR 1.07, 95% CI 1.04, 1.11, respectively; P for trend <.0001). No associations were observed between baseline BMI category and hospitalizations in the adjusted analyses. ConclusionsChildren who are overweight or obese utilize the ED and outpatient clinics more frequently than those who are underweight/healthy weight, but are not hospitalized more frequently.

Demand survey of medical record information for at all levels of nursing staff

Objective To survey the current demand of medical record information for at all levels of nursing staff in grade three class A hospital. Methods Questionnaire for demand of medical record information was designed, then nursing staff at grade three general hospital were investigated, in order to understand the need of medical record information for at all levels of nursing staff, and analyze the characteristics of need. Results Different occupational title had different demand on writing thesis, research proposal and knowledge accumulation and update when they referred to medical record information (χ2=37.260, 48.948, 19.399; P 0.05). Conclusions The demand of different level nursing staff should be considerate to improve the model of medical records service and provide corresponding services to enhance the utilization of medical records information among nursing staffs. Key words: General hospital; Nursing staff; Occupational title; Medical record information; Demand

Smoking Status and Pain Intensity Among OEF/OIF/OND Veterans.

Pain and smoking are highly prevalent among Veterans. Studies in non-Veteran populations have reported higher pain intensity among current smokers compared with nonsmokers and former smokers. We examined the association of smoking status with reported pain intensity among Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). The sample consisted of OEF/OIF/OND Veterans who had at least one visit to Veterans Affairs (2001-2012) with information in the electronic medical record for concurrent smoking status and pain intensity. The primary outcome measure was current pain intensity, categorized as none to mild (0-3); moderate (4-6); or severe (≥7); based on a self-reported 11-point pain numerical rating scale. Multivariable logistic regression analyses were used to assess the association of current smoking status with moderate to severe (≥4) pain intensity, controlling for potential confounders. Overall, 50,988 women and 355,966 men Veterans were examined. The sample mean age was 30 years; 66.3% reported none to mild pain; 19.8% moderate pain; and 13.9% severe pain; 37% were current smokers and 16% former smokers. Results indicated that current smoking [odds ratio (OR) = 1.29 (95% confidence intervals (CI) = 1.27-1.31)] and former smoking [OR = 1.02 (95% CI = 1.01-1.05)] were associated with moderate to severe pain intensity, controlling for age, service-connected disability, gender, obesity, substance abuse, mood disorders, and Post Traumatic Stress Disorder. We found an association between current smoking and pain intensity. This effect was attenuated in former smokers. Our study highlights the importance of understanding reported pain intensity in OEF/OIF/OND Veterans who continue to smoke.

Abstract 5590: Reliability of medical records in diagnosing inflammatory breast cancer in Egypt

Abstract Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer characterized by diffuse erythema and edema (peau d’orange) of the skin of the breast. It does not include neglected locally advanced cancer of the breast presenting late in the course of the disease. IBC is primarily a clinical diagnosis, but also requires pathologic confirmation of breast cancer. The purpose of this study was to examine the reliability of medical records for diagnosing IBC in patients at two centers in Tanta, Egypt (Gharbiah Cancer Society and Tanta Cancer Center) which participated in an epidemiologic case-case study of IBC and non-IBC in 2009-2010. IBC patients were recruited to the case-case study at diagnosis based on clinical examination; detailed information on the extent and duration of signs used for the diagnosis of IBC was recorded. Information on signs of IBC similar to those collected in the case-case study was abstracted from the medical records of the hospitals where case-case study patients were recruited during the same time period, then linked and compared to the signs observed from clinical examination for the case-case study. A total of 40 IBC cases were recruited into the case-case study during 2009-2010. Medical record information was available for 31 of these cases. Twenty-eight of these 31 cases were reported to have erythema and 28 edema/peau d’orange based on the clinical examination for the case-case study. Of those with erythema, 16 (57.1%) also had erythema/inflammation listed in the medical record; of those with edema/peau d’orange, 23 (82.1%) had this mentioned in the medical record. Erythema was noted on the medical record but not recorded in the case-case study for 2 cases; there were no cases in which edema/peau d’orange was present in the medical record and not in the case-case study. Our analysis indicates that medical records at these cancer centers often have missing information regarding the presence of signs that are necessary to the diagnosis of IBC. Overall, this study suggests that medical record review is not sufficient to identify IBC cases for an epidemiologic study. Citation Format: Lynne Le, Catherine Schairer, Ahmed Hablas, Mohamed Ramadan, Sofia Merajver, Ibrahim Seifeldein, Amr Soliman. Reliability of medical records in diagnosing inflammatory breast cancer in Egypt. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5590. doi:10.1158/1538-7445.AM2015-5590

Variations in adjuvant chemotherapy and survival in women with epithelial ovarian cancer – a population-based study

Background. To investigate whether variations in primary chemotherapy were associated with survival in a nationally complete cohort of Australian women with epithelial ovarian cancer (EOC).Material and methods. All 1192 women diagnosed with invasive EOC in Australia in 2005 were identified through state-based cancer registries. Medical record information including details of primary chemotherapy treatment was obtained and survival data updated in 2012. Those started on standard chemotherapy (carboplatin and paclitaxel given at three-weekly intervals) after primary cytoreductive surgery were included (n = 351) and the relative dose intensity (RDI) was calculated. Time interval between surgery and start of chemotherapy was analysed in weeks. Hazard ratios [HR, 95% confidence interval (CI)] were calculated using multivariable Cox proportional hazards models.Results. Compared to women with RDI of 91–100%, those with RDI of ≤ 70% had significantly poor survival (HRadj = 1.62, 95% CI 1.05–2.49). This association was stronger among women with advanced (FIGO stage III/IV) disease at diagnosis (HRadj = 1.90, 95% CI 1.22–2.96). The interval between primary surgery and chemotherapy was not related to survival (HRadj = 0.98, 95% CI 0.93–1.03 for every week of delay), at least up to a period of five weeks.Conclusion. Our results suggest that RDI of 70% or less was associated with poorer survival, particularly in women with advanced stage EOC. In contrast, the interval duration between primary surgery and chemotherapy was not related to survival, irrespective of disease stage or residual disease. These results provide some reassurance that, at least up until five weeks post-surgery, timing of chemotherapy commencement has a negligible effect on survival.

Reliability and validity of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in evaluations of chronic low back pain patients.

The purpose of the current study was to investigate the reliability and concurrent validity of Minnesota Multiphasic Personality Inventory (MMPI)-2-Restructured Form (2-RF) (Ben-Porath & Tellegen, 2008/2011) scores in a sample of 811 chronic low back pain patients (346 males, 529 females) beginning treatment in a short-term interdisciplinary pain rehabilitation program. We calculated internal consistency coefficients, mean-item correlations, and SEM for all substantive scales, as well as zero-order correlations with collateral medical record information and self-report testing. Results indicated reliability and validity for most of the MMPI-2-RF substantive scales. Implications of these findings and limitations of this study are discussed.

Which information source is best? Concordance between patient report, clinician report and medical records of patient co-morbidity and adjuvant therapy health information.

Previous studies investigating agreement between data sources for co-morbidity and adjuvant therapy information have suggested agreement varies depending on how the information is collected. The aim of this study was to compare agreement among three data sources: patient report, clinician report and medical record. Data were collected as part of a nurse-delivered telephone intervention (the CONNECT programme). Patient report was collected using a self-administered questionnaire. Clinician report was collected from the patient's treating surgeon. Medical record information was extracted by a member of the research team. The proportion of specific agreement [positive (PA) and negative agreement (NA)] and Kappa statistics were calculated. The study sample comprised 756 surgical patients with colorectal cancer. For the majority of co-morbidities the lowest level of agreement was found between the patient and clinician (PA 0.29-0.64, Kappa values ranged from 0.22 to 0.58). The highest agreement and Kappa values for co-morbidities were generally found between the patient report and medical record (PA 0.36-0.80 and NA 0.92-0.99; Kappa 0.34-0.77). There was good agreement between patient and clinician reports for receipt adjuvant therapy {Kappa 0.78 [confidence interval (CI) 0.72-0.84] and 0.84 [CI 0.80-0.88], respectively; PA 0.87 and 0.92, respectively}. No consistent pattern in the predictors of non-agreement was found. Given there was higher agreement between patient report and medical record review, the use of patient self-report questionnaires to ascertain co-morbid conditions remains a valid method for health services research.

Abstract W P353: Stroke Beat the Clock: A Lesson in Staff Engagement for Quality Stroke Care

Background and Purpose: The introduction and continued growth in electronic medical record use introduced overall challenges in filtering critical information on stroke and TIA patients, and an opportunity for improvement in chart navigation in the care of stroke patients. The purpose for the game was to improve the ease of navigating the patient’s course of treatment from arrival through discharge in a timely and efficient manner. Methods: The game was developed to familiarize the stroke unit staff nurses with pertinent information in the electronic medical record. The navigational guide was distributed to the staff for study or review prior to the onset of the game. Each day tracers were completed using designated charts for speed, accuracy and care plan development. Prizes were given for participation, champions posted daily and the overall winners were recognized by the department as well as a hospital board member, a local stroke champion. Results: Every participating nurse improved in both time and accuracy during the eight week period. There was an increased participation of this new process as it afforded the staff the ability to independently summarize a patient’s course of treatment in a shortened period of time. Subsequently, there were requests for similar tools for additional disease processes. Concurrent chart reviews showed better documentation in plan of care development, increased productivity, and improved connection with patient and family members. Conclusions: Stroke Beat the Clock proved to be an effective tool in teaching the nurses how to navigate the electronic medical record for pertinent information from patient arrival to discharge accurately. Improvements in speed with consistency provided the nurses a better understanding of patient care as they coordinate with the multidisciplinary team involved in stroke care and recovery.

Guideline concordant detection and management of depression among Alaska Native and American Indian people in primary care

BackgroundA tribal health organization in Alaska implemented a primary care depression screening, detection and management initiative amongst 55,000 Alaska Native/American Indian people (AN/AIs).Objectives(a) To describe the proportion of AN/AIs screening positive for depression with depression noted or diagnosed and proportion with guideline concordant management and (b) to assess whether management varied by patient and provider factors.Research designSecondary analysis of electronic and paper medical record information of 400 AN/AIs.MeasuresProvider variables, patient demographics and patient clinical factors were electronically queried. Manual chart audits assessed depression notation, diagnoses and management within 12 weeks of positive screening. Multilevel ordinal logistic modelling assessed management by patient and provider factors.ResultsA depression diagnosis was present in 141 (35%) charts and 151 (38%) had depressive symptoms noted. Detection was higher among AN/AIs with moderate and severe depression (p<0.001). In total, 258 patients (66%) received guideline concordant management, 32 (8%) had some management, and 110 (28%) received no management. Younger patient age and increased provider tenure increased odds of management.ConclusionsMost AN/AIs screening positive for depression received initial guideline concordant management. Additional outreach to older patients and additional support for providers newer to practices appears warranted.

Patterns and predictors of sleep quality before, during, and after hospitalization in older adults.

The impact of hospitalization on sleep in late-life is underexplored. The current study examined patterns of sleep quality before, during, and following hospitalization, investigated predictors of sleep quality patterns, and examined predictors of classification discordance between two suggested clinical cutoffs used to demarcate poor/good sleep. This study included older adults (n = 163; mean age 79.7 ± 6.9 years, 31% female) undergoing inpatient post-acute rehabilitation. Upon admission to inpatient post-acute rehabilitation, patients completed the Pittsburgh Sleep Quality Index (PSQI) retrospectively regarding their sleep prior to hospitalization. They subsequently completed the PSQI at discharge, and 3 months, 6 months, 9 months, and 1 year post discharge. Patient demographic and clinical characteristics (pain, depression, cognition, comorbidity) were collected upon admission. Using latent class analysis methods, older adults could be classified into (1) Consistently Good Sleepers and (2) Chronically Poor Sleepers based on patterns of self-reported sleep quality pre-illness, during, and up to 1 year following inpatient rehabilitation. This pattern was maintained regardless of the clinical cutoff employed (> 5 or > 8). Logistic regression analyses indicated that higher pain and depressive symptoms were consistently associated with an increased likelihood of being classified as a chronic poor sleeper. While there was substantial classification discordance based on clinical cutoff employed, no significant predictors of this discordance emerged. Clinicians should exercise caution in assessing sleep quality in inpatient settings. Alterations in the cutoffs employed may result in discordant clinical classifications of older adults. Pain and depression warrant detailed considerations when working with older adults on inpatient units when poor sleep is a concern.

Investigating selected patient safety indicators using medical records data.

Introduction:Medical errors in hospitals kill more people every year than AIDS, breast cancer and auto accidents combined. Widespread consensus exists that health care organizations can reduce patient injuries by improving the environment for safety from implementing different alternatives from technical and managerial improvements to considering medical record data. Considering the preventability of medical errors, the Agency for Healthcare Quality and Research (AHRQ) developed patient safety indicators (PSIs). This study analyzes the PSIs calculated in Alzahra Hospital of Isfahan.Materials and Methods:This study was conducted retrospectively using the inpatient medical record data of hospitalized patients in a six month period, from October 2010 to March 2011. An experienced team in the fields of medical record, health management and health information technology was involved in data reviewing. Based on a prior consultation and reviewing, some PSIs were selected. Indicators were calculated considering AHRQ guidelines. Excel software and hospital information system software were used.Results:Across all studied medical records of patients, out of 25,164 discharges, below measures were calculated.-8 Foreign Body cases (PSI 5) (0.31 per 1000).-30 Postoperative Hemorrhage or Hematoma cases (PS I9) (2.2 per 1000).-5 Accidental Puncture or Laceration cases (PSI 15) (0.3 per1000).-8 Complications of Anesthesia cases (PSI 1) (2.2 per 1000).-96 Selected Infections Due to Medical Care cases (PSI 7) (3.8 per1000).-17 cases of Postoperative Wound Dehiscence (PSI 14) (3.7per1000).-1 Birth Trauma – Injury to Neonate case, and (PSI 17) (1.7 per 1000).- 18 Obstetric Trauma – Cesarean Delivery cases (PSI 20) (40 per 1000) were flagged by studied PSIs developed by AHRQ.Conclusion:Comparing with the reported rates by other studies and AHRQ study in 2006, all of calculated indicators have inadequate condition; i.e. these are far from empirical estimated rates. The hospital administrators should be more sensitive to this issue and perform some improvement programs.

The correlation analysis of primary liver cancer with Type 2 diabetes.

To explore the relationship between Type 2 diabetes and primary liver cancer. In the period from December 2008 to December 2014, all blood sugar data of patients in our hospital was collected, and the total number is 18213. Except for repeatedly hospitalized diabetic person, newborn stress status, or venous transfusion blood glucose, gestational diabetes, etc., By retrieving the medical record information of patients in the hospital, and using telephone or letter follow-up the patients, we collected 127 people with type 1 diabetes and found no liver cancer patients; Type 2 diabetes, 10,794 cases of patient information, 59 with primary liver cancer. For data analysis, Stata11.0 ratio was used as the main analysis indicators, using Chi-square test and statistical analysis. About 10,794 Type 2 diabetes cases with 59 primary liver cancer, the incidence is 54.66/10,000, men liver cancer incidence (92.78/10,000) than women (27.13/10,000), with significant difference (χ2 = 26.621, P < 0.001). As the growth of the age, the possibility of liver cancer in patients with diabetes increased significantly (χ2 = 19.961, P = 0.001). The rate was highest for 50-60-year-old men, and the women at age 70, and older incidence is highest. Irrespective of men or women with diabetes as the growth of the age, the possibility of liver cancer had significantly increased (P = 0.001, P = 0.002). Hepatitis B or hepatitis C incidence was 2.94%, but diabetes incidence of hepatitis men (3.98%) and women (2.01%) did not find significant differences (χ2 = 0.3361, P = 0.562). Three hundred and seventeen cases of Type 2 diabetes with hepatitis, the incidence of primary liver cancer was 11.67%, the liver cancer incidence of diabetes patients with hepatitis men (17.78%) than women (3.97%), with significant difference (χ2 = 37.429, P < 0.001). With the growth of age, the overall risk of getting liver cancer (χ2 =15.023, P = 0.01) of diabetes and hepatitis patients is significantly increased, and with the growth of age, the risk of getting liver cancer of male patients showed significant (P < 0.05), but not the female patients. Without merge hepatitis, the morbility of primary liver cancer in 10477 cases of type2 diabetes incidence is 0.21%, the liver cancer incidence men (0.34%) than women (0.11%), with significant difference (χ2 = 6.471, P = 0.011).As the growth of age, the overall risk of getting liver cancer of diabetes patients without hepatits is significantly increased (χ2 =15.612, P = 0.008) ,and the risk of getting liver cancer of male patients showed significant (P < 0.05) as the growth of the age, but not the female patients. Diabetic persons according to the illness time can be divided into 0-5 years, 5-10 years, 10-20 years, and over 20 years of four stages, including 5-10 years and 10-20 years is liver cancer patients with diabetes incidence peak, male diabetic hepatitis in patients with liver cancer incidence than women, with significant difference (χ2 = 22.757, P < 0.001). The possibility of liver cancer in patients with diabetes increased significantly (χ2 = 15.023, P = 0.01) for longer duration of illness, but only the male patients with liver cancer incidence showed significant difference with longer duration of illness, women showed no significance. Diabetes was associated with the primary liver cancer, most likely is one of the causes of primary liver cancer.

Morning handover of on-call issues: opportunities for improvement.

Handover is the process of transferring pertinent patient information and clinical responsibility between health care practitioners. Few studies have examined morning handover from the overnight trainee to the daytime team. To characterize current morning handover practices in 2 academic medical centers by assessing the frequency of omissions of clinically important overnight issues during morning handover and identifying factors that influence the occurrence of such omissions. A prospective, point-prevalence study was conducted in the general internal medicine wards of 2 tertiary care academic medical centers in Toronto, Ontario, Canada, in 2012 and 2013. Participants included on-call third-year medical students and first- and second-year residents. Completeness of morning handover of clinically important overnight issues identified using a targeted medical records review and processes of morning handover characterized by direct observation. We identified 141 clinically important overnight issues during 26 days of observation. The on-call trainee omitted 40.4% (95% CI, 32.3%-48.5%) of clinically important issues during morning handover and did not document any information in the patient's medical record for 85.8% (95% CI 80.1%-91.6%) of these issues. By univariate analysis, running the list patient-by-patient (ie, the entire team discusses each patient) (OR, 4.32; 95% CI, 1.94-9.60; P < .001) and using a dedicated handover location (OR, 2.61; 95% CI, 1.30-5.22; P = .007) positively correlated with handover of an issue taking place, whereas distractions in the meeting area inversely correlated with the likelihood of handover of an issue taking place (OR, 0.96 for every increase in 1 distraction; 95% CI, 0.93-0.98; P = .002). Using a multivariate mixed-effects model, only running the list remained as an independent predictor of the handover of an issue (OR, 3.80; 95% CI, 1.25-11.49; P = .02). On-call trainees omit numerous clinically important issues when handing over to the daytime team. Training programs should introduce educational activities and workflow changes, and provide dedicated time and a distraction-free environment, to improve handover of on-call issues.

Pengembangan Sistem Informasi Rekam Medis untuk Dinas Kabupaten Grobogan

Abstract - Health services include the recording of the patient's medical record . Medical records were used to aid the treatment process. The number of medical records continues to grow proportional to the number of patients. Tens of thousands of sheets of paper used to record medical record requires effort , time and place great . The amount of effort will continue to grow each day. Search one sheet of medical records among a set of storage shelves requires considerable time and risk data is not found. The risk of error in the search and storing will increase every day. The development of technology allows the implementation of technology in the process of record-keeping. Changes in the form of digital medical records will reduce the need of a previous process. Labor, time and place required by the help of information systems will be reduced significantly . Storage process data stored in the cloud will provide more value for the system as a patient's medical records from a health center can be accessed from other health centers. The development of this system will reduce the risk of inappropriate storage and retrieval of medical records. Grobogan Health Department that oversees health center in Grobogan are office that are ready to migrate business processes into the digital age. Development of medical record information system for the health center expected to improve the quality of service of health centers , especially in health care.

The Use of Medical Record Information in the 2011 Version of the Accreditation Standards for a Level 3 General Hospital

AbstractThe 2011 version of the accreditation standards for a level 3 general hospital relates to descriptions about the use of medical record information; 636 entries in 378 items and 48 core indexes in seven chapters relate to medical record information. Of these items, 103, accounting for 27.25%, relate to all chapters, and 22 relate to core entries, accounting for 45.83%. Chapter seven almost fully concerns daily statistical evaluation. There are at least about 150 links that should be carried out in combination with medical records in the process of accreditation, and therefore, the importance and effect of medical records in accreditation becomes obvious. The hospital accreditation standards further suggest that the science, discipline construction, and continuous improvement of medical information management should be given the same priority as record writing quality in hospital development, and thereby medical information can be used effectively.