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Sample records for duplicate medical records

  1. Duplicate Medical Records: A Survey of Twin Cities Healthcare Organizations

    PubMed Central

    McClellan, Molly A.

    2009-01-01

    Duplicate medical records occur when a single patient is associated with more than one medical record number. This causes a dangerous and expensive issue for hospitals and health information technology. A survey was constructed to gather qualitative information from Twin Cities healthcare organizations. The goal was to determine baseline information regarding the recognition of the problems surrounding duplicate medical record creation and organizational strategies for resolutions. The survey demonstrated that all organizations acknowledged the importance and patient safety issue regarding the creation of duplicates but the strategies and solutions are varied. As defined in the Minnesota Alliance for Patient Safety5, the ultimate goal of this survey was to favorably impact patient safety. The deidentified results were disseminated to all participating organizations along with recommendations for system improvements in order to raise awareness of the issue and promote patient safety. PMID:20351892

  2. Electronic Documentation Support Tools and Text Duplication in the Electronic Medical Record

    ERIC Educational Resources Information Center

    Wrenn, Jesse

    2010-01-01

    In order to ease the burden of electronic note entry on physicians, electronic documentation support tools have been developed to assist in note authoring. There is little evidence of the effects of these tools on attributes of clinical documentation, including document quality. Furthermore, the resultant abundance of duplicated text and…

  3. Identifying and removing duplicate records from systematic review searches

    PubMed Central

    Kwon, Yoojin; Lemieux, Michelle; McTavish, Jill; Wathen, Nadine

    2015-01-01

    Objective The purpose of this study was to compare effectiveness of different options for de-duplicating records retrieved from systematic review searches. Methods Using the records from a published systematic review, five de-duplication options were compared. The time taken to de-duplicate in each option and the number of false positives (were deleted but should not have been) and false negatives (should have been deleted but were not) were recorded. Results The time for each option varied. The number of positive and false duplicates returned from each option also varied greatly. Conclusion The authors recommend different de-duplication options based on the skill level of the searcher and the purpose of de-duplication efforts. PMID:26512216

  4. The impact of a growing minority population on identification of duplicate records in an enterprise data warehouse.

    PubMed

    Duvall, Scott L; Fraser, Alison M; Kerber, Richard A; Mineau, Geraldine P; Thomas, Alun

    2010-01-01

    Patient medical records are often fragmented across disparate healthcare databases, potentially resulting in duplicate records that may be detrimental to health care services. These duplicate records can be found through a process called record linkage. This paper describes a set of duplicate records in a medical data warehouse found by linking to an external resource containing family history and vital records. Our objective was to investigate the impact database characteristics and linkage methods have on identifying duplicate records using an external resource. Frequency counts were made for demographic field values and compared between the set of duplicate records, the data warehouse, and the external resource. Considerations for understanding the relationship that records labeled as duplicates have with dataset characteristics and linkage methods were identified. Several noticeable patterns were identified where frequency counts between sets deviated from what was expected including how the growth of a minority population affected which records were identified as duplicates. Record linkage is a complex process where results can be affected by subtleties in data characteristics, changes in data trends, and reliance on external data sources. These changes should be taken into account to ensure any anomalies in results describe real effects and are not artifacts caused by datasets or linkage methods. This paper describes how frequency count analysis can be an effective way to detect and resolve anomalies in linkage results and how external resources that provide additional contextual information can prove useful in discovering duplicate records. PMID:20841858

  5. Your Medical Records

    MedlinePlus

    ... to get records for non-emergency situations (like switching to a new doctor), it's best to give ... Your Medical Care Health Insurance Basics Finding Low-Cost Medical Care Health Insurance: Cracking the Code Questions ...

  6. Access to Medical Records.

    ERIC Educational Resources Information Center

    Cooper, Nancy

    Although confidentiality with regard to medical records is supposedly protected by the American Medical Associaton's principles of Ethics and the physician-patient privilege, there are a number of laws that require a physician to release patient information to public authorities without the patient's consent. These exceptions include birth and…

  7. 14 CFR 1212.606 - Duplicate copies of records or portions of records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 5 2010-01-01 2010-01-01 false Duplicate copies of records or portions of records. 1212.606 Section 1212.606 Aeronautics and Space NATIONAL AERONAUTICS AND SPACE ADMINISTRATION... practice should occur only where there are justifiable organizational needs for it, e.g., where...

  8. Private Medical Record Linkage with Approximate Matching

    PubMed Central

    Durham, Elizabeth; Xue, Yuan; Kantarcioglu, Murat; Malin, Bradley

    2010-01-01

    Federal regulations require patient data to be shared for reuse in a de-identified manner. However, disparate providers often share data on overlapping populations, such that a patient’s record may be duplicated or fragmented in the de-identified repository. To perform unbiased statistical analysis in a de-identified setting, it is crucial to integrate records that correspond to the same patient. Private record linkage techniques have been developed, but most methods are based on encryption and preclude the ability to determine similarity, decreasing the accuracy of record linkage. The goal of this research is to integrate a private string comparison method that uses Bloom filters to provide an approximate match, with a medical record linkage algorithm. We evaluate the approach with 100,000 patients’ identifiers and demographics from the Vanderbilt University Medical Center. We demonstrate that the private approximation method achieves sensitivity that is, on average, 3% higher than previous methods. PMID:21346965

  9. Confidentiality and medical records

    PubMed Central

    Jones, R. V. H.; Richards, S. Jane

    1978-01-01

    Protecting confidential information disclosed to doctors has been one of the most important ethical traditions of the medical profession. However, the patient's right to such confidentiality is threatened because it is legally unclear how far ownership by Government of the paper on which NHS records are kept or of the computer system in which they are stored confers right of access. We hope the medical profession will examine this problem urgently and offer some suggestions as to how patients' confidences can continue to be protected in the future. PMID:702427

  10. Computerized medication administration records decrease medication occurrences.

    PubMed

    Wilson, A L; Hill, J J; Wilson, R G; Nipper, K; Kwon, I W

    1997-04-01

    Studies have demonstrated that medication errors occur at a number of locations in the continuum between ordering of drug therapy and administration of the medication. Computer management of patient medication profiles offers the opportunity to enhance communication between pharmacists and nurses, and to decrease medication errors and delays in delivery of therapy. A number of authors have postulated that computerization of medication profiles would enhance medication delivery accuracy and timeliness, but no study has demonstrated this improvement. We report the results of a retrospective analysis undertaken to assess the improvements resulting from sharing a computerized medication record. We used a broader definition of medication occurrences that includes the more traditional definition, and averted errors, delays in delivery of medications and information, and disagreements between pharmacy and nursing medication profiles. We compared medication occurrences reported through an existing internal system between two periods; the first when separate pharmacy and nursing medication records were used, and the second period when a shared medication record was used by pharmacy and nursing. Average medication occurrences per admission decreased from 0.1084 to 0.0658 (p < 0.01). Medication occurrences per dose decreased from 0.0005 to 0.0003 (p < 0.01). The use of a shared medication record by pharmacy and nursing led to a statistically significant decrease in medication occurrences. Information shared between the two professions allowed timely resolution of discrepancies in medication orders, leading to better execution of drug therapy, decreased medication occurrences, and increased efficiency. PMID:10166241

  11. Medical records and record-keeping standards.

    PubMed

    Carpenter, Iain; Ram, Mala Bridgelal; Croft, Giles P; Williams, John G

    2007-08-01

    The structure of medical records becomes ever more critical with the advent of electronic records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Records Standards programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and discharge records. The Information Laboratory (iLab) focuses on hospital episode statistics and their use for monitoring clinician performance. Clinician endorsement of the work is achieved through extensive consultations. Generic medical record-keeping standards are now available. PMID:17882846

  12. Effects of Shared Electronic Health Record Systems on Drug-Drug Interaction and Duplication Warning Detection

    PubMed Central

    Rinner, Christoph; Grossmann, Wilfried; Sauter, Simone Katja; Wolzt, Michael; Gall, Walter

    2015-01-01

    Shared electronic health records (EHRs) systems can offer a complete medication overview of the prescriptions of different health care providers. We use health claims data of more than 1 million Austrians in 2006 and 2007 with 27 million prescriptions to estimate the effect of shared EHR systems on drug-drug interaction (DDI) and duplication warnings detection and prevention. The Austria Codex and the ATC/DDD information were used as a knowledge base to detect possible DDIs. DDIs are categorized as severe, moderate, and minor interactions. In comparison to the current situation where only DDIs between drugs issued by a single health care provider can be checked, the number of warnings increases significantly if all drugs of a patient are checked: severe DDI warnings would be detected for 20% more persons, and the number of severe DDI warnings and duplication warnings would increase by 17%. We show that not only do shared EHR systems help to detect more patients with warnings but DDIs are also detected more frequently. Patient safety can be increased using shared EHR systems. PMID:26682218

  13. Keeping a Personal Medical Record

    MedlinePlus

    ... from an appointment Store records online using an e-health tool; certain online records tools may be accessed, ... Medical Record Medline Plus: Personal Health Records American Health Information Management Association: myPHR Log in or register to post ... Home Types of Cancer Navigating Cancer Care ...

  14. Medical narratives in electronic medical records.

    PubMed

    Tange, H J; Hasman, A; de Vries Robbé, P F; Schouten, H C

    1997-08-01

    In this article, we describe the state of the art and directions of current development and research with respect to the inclusion of medical narratives in electronic medical-record systems. We used information about 20 electronic medical-record systems as presented in the literature. We divided these systems into 'classical' systems that matured before 1990 and are now used in a broad range of medical domains, and 'experimental' systems, more recently developed and, in general, more innovative. In the literature, three major challenges were addressed: facilitation of direct data entry, achieving unambiguous understandability of data, and improvement of data presentation. Promising approaches to tackle the first and second challenge are the use of dynamic data-entry forms that anticipate sensible input, and free-text data entry followed by natural-language interpretation. Both these approaches require a highly expressive medical terminology. How to facilitate the access to medical narratives has not been studied much. We found facilitating examples of presenting this information as fluent prose, of optimising the screen design with fixed position cues, and of imposing medical narratives with a structure of indexable paragraphs that can be used in flowsheets. We conclude that further study is needed to develop an optimal searching structure for medical narratives. PMID:9476152

  15. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  16. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 4 2011-10-01 2011-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  17. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  18. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Medical records. 460.210 Section 460.210 Public...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of medical records. (1) A PACE organization must maintain a single, comprehensive medical record for...

  19. Medical records and access thereto.

    PubMed

    McQuoid-Mason, D

    1996-01-01

    Medical records are essential tools in the practice of medicine. They are important in the planning and monitoring of patient care and for the protection of the legal interests of patients, hospitals and doctors. There is a legal duty on doctors to maintain confidentiality and failure to do so may result in an action for invasion of privacy, defamation or even breach of contract. There are, however, exceptions to this rule. There are procedural remedies available to obtain access to medical records where they are relevant to civil or criminal proceedings. There are also constitutional provisions under the Interim and Working Draft Constitutions which may allow such access. The former only applies to records held by the state while the latter applies to both state and privately held records. Ownership of medical records usually vests in the doctor or institution treating the patient, but such ownership is custodial rather than absolute. Patient records should be accurate, objective and contemporaneous. The international trend is to allow patients to inspect their records and to allow them to make copies thereof. It is submitted that given the provisions of the Interim and Working Draft Constitutions the same should apply in South Africa. PMID:9009602

  20. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 2 2014-07-01 2014-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  1. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 2 2011-07-01 2011-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  2. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  3. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 2 2012-07-01 2012-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  4. 32 CFR 321.6 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 2 2013-07-01 2013-07-01 false Medical records. 321.6 Section 321.6 National... DEFENSE SECURITY SERVICE PRIVACY PROGRAM § 321.6 Medical records. General. Medical records that are part... upon the individual's physical or mental health, the medical record in question will be released...

  5. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 21 Food and Drugs 1 2013-04-01 2013-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an individual is entitled to have access to any medical records about himself in Privacy Act Record...

  6. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 21 Food and Drugs 1 2012-04-01 2012-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an individual is entitled to have access to any medical records about himself in Privacy Act Record...

  7. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 21 Food and Drugs 1 2011-04-01 2011-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an individual is entitled to have access to any medical records about himself in Privacy Act Record...

  8. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 21 Food and Drugs 1 2014-04-01 2014-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an individual is entitled to have access to any medical records about himself in Privacy Act Record...

  9. 21 CFR 21.33 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 21 Food and Drugs 1 2010-04-01 2010-04-01 false Medical records. 21.33 Section 21.33 Food and... PRIVACY Requirements for Specific Categories of Records § 21.33 Medical records. (a) In general, an individual is entitled to have access to any medical records about himself in Privacy Act Record...

  10. Access to children's medical records.

    PubMed

    Bird, Sara

    2008-06-01

    Case histories are based on actual medical negligence claims or medicolegal referrals; however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. When the parents of a young child are separated or divorced, it is not uncommon for general practitioners to receive requests from one of the parents for information about the medical management of the child, including a request for a copy of the child's medical records. The role of the GP is to provide medical care to the child and act in the child's best interests. This article outlines some strategies for GPs to minimise the possibility of becoming 'piggy in the middle' of a dispute between the parents. PMID:18523700

  11. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2013-07-01 2013-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care... and Covered Birth Defects § 17.905 Medical records. Copies of medical records generated outside...

  12. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2014-07-01 2014-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care... and Covered Birth Defects § 17.905 Medical records. Copies of medical records generated outside...

  13. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2011-07-01 2011-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care... and Covered Birth Defects § 17.905 Medical records. Copies of medical records generated outside...

  14. 36 CFR 1238.16 - What are the microfilming requirements for temporary records, duplicates, and user copies?

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 36 Parks, Forests, and Public Property 3 2012-07-01 2012-07-01 false What are the microfilming requirements for temporary records, duplicates, and user copies? 1238.16 Section 1238.16 Parks, Forests, and Public Property NATIONAL ARCHIVES AND RECORDS ADMINISTRATION RECORDS MANAGEMENT MICROFORMS RECORDS MANAGEMENT Microfilming Standards §...

  15. A computerized obstetric medical record.

    PubMed

    Stead, W W; Brame, R G; Hammond, W E; Jelovsek, F R; Estes, E H; Parker, R T

    1977-04-01

    Duke University has utilized computerized obstetric medical records since 1971. System evolution is described. Deficiencies in the current system appear to evolve from the computer/human interface rather than from basic system design. Critical elements in system success are physician acceptance of the appearance of data collection sheets and printed notes and continual rapid response in programing modification to allow for physician individuality and changes in medical practice. The limiting factor in the potential usefulness of such a system is the rate of incomplete data collection. It is suggested that if the physician were to enter data directly into the computer through a terminal, data collection would be more accurate and complete. PMID:854253

  16. The Effect of Adoption of an Electronic Health Record on Duplicate Testing

    PubMed Central

    Kerwin, Todd C.; Leighton, Harmony; Buch, Kunal; Avezbadalov, Azriel; Kianfar, Hormoz

    2016-01-01

    Background. The electronic health record (EHR) has been promoted as a tool to improve quality of patient care, reduce costs, and improve efficiency. There is little data to confirm that the use of EHR has reduced duplicate testing. We sought to evaluate the rate of performance of repeat transthoracic echocardiograms before and after the adoption of EHR. Methods. We retrospectively examined the rates of repeat echocardiograms performed before and after the implementation of an EHR system. Results. The baseline rate of repeat testing before EHR was 4.6% at six months and 7.6% at twelve months. In the first year following implementation of EHR, 6.6% of patients underwent a repeat study within 6 months, and 12.9% within twelve months. In the most recent year of EHR usage, 5.7% of patients underwent repeat echocardiography at six months and 11.9% within twelve months. All rates of duplicate testing were significantly higher than their respective pre-EHR rates (p < 0.01 for all). Conclusion. Our study failed to demonstrate a reduction in the rate of duplicate echocardiography testing after the implementation of an EHR system. We feel that this data, combined with other recent analyses, should promote a more rigorous assessment of the initial claims of the benefits associated with EHR implementation. PMID:27088033

  17. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 3 2013-01-01 2013-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  18. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 5 Administrative Personnel 3 2011-01-01 2011-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  19. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 5 2011-07-01 2011-07-01 false Medical records. 701.122 Section 701.122... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... requirements of DOD 6025.18-R. (b) Disclosure. DON activities shall disclose medical records to the...

  20. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  1. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 5 2014-07-01 2014-07-01 false Medical records. 701.122 Section 701.122... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... requirements of DOD 6025.18-R. (b) Disclosure. DON activities shall disclose medical records to the...

  2. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 5 2010-07-01 2010-07-01 false Medical records. 701.122 Section 701.122... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... requirements of DOD 6025.18-R. (b) Disclosure. DON activities shall disclose medical records to the...

  3. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 5 Administrative Personnel 3 2014-01-01 2014-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  4. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 5 2013-07-01 2013-07-01 false Medical records. 701.122 Section 701.122... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... requirements of DOD 6025.18-R. (b) Disclosure. DON activities shall disclose medical records to the...

  5. 5 CFR 1830.3 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 5 Administrative Personnel 3 2012-01-01 2012-01-01 false Medical records. 1830.3 Section 1830.3 Administrative Personnel OFFICE OF SPECIAL COUNSEL PRIVACY § 1830.3 Medical records. When a request for access involves medical records that are not otherwise exempt from disclosure, the requesting individual may...

  6. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 5 2012-07-01 2012-07-01 false Medical records. 701.122 Section 701.122... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... requirements of DOD 6025.18-R. (b) Disclosure. DON activities shall disclose medical records to the...

  7. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 22 Foreign Relations 2 2010-04-01 2010-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  8. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 2 2014-01-01 2014-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  9. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 22 Foreign Relations 2 2013-04-01 2009-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  10. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 22 Foreign Relations 2 2014-04-01 2014-04-01 false Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  11. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 14 Aeronautics and Space 2 2011-01-01 2011-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  12. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 14 Aeronautics and Space 2 2013-01-01 2013-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  13. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 14 Aeronautics and Space 2 2012-01-01 2012-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  14. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 22 Foreign Relations 2 2011-04-01 2009-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  15. 22 CFR 505.6 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 22 Foreign Relations 2 2012-04-01 2009-04-01 true Medical records. 505.6 Section 505.6 Foreign Relations BROADCASTING BOARD OF GOVERNORS PRIVACY ACT REGULATION § 505.6 Medical records. If, in the judgment of the Agency, the release of medical information to you could have an adverse effect, the...

  16. 14 CFR 67.413 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 2 2010-01-01 2010-01-01 false Medical records. 67.413 Section 67.413 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) AIRMEN MEDICAL STANDARDS AND CERTIFICATION Certification Procedures § 67.413 Medical records. (a) Whenever...

  17. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) Data Collection, Record Maintenance, and Reporting § 460.210 Medical records. (a) Maintenance of...) Authentication must include signatures or a secured computer entry by a unique identifier of the primary...

  18. Implementation of electronic medical records

    PubMed Central

    Greiver, Michelle; Barnsley, Jan; Glazier, Richard H.; Moineddin, Rahim; Harvey, Bart J.

    2011-01-01

    Abstract Objective To apply the diffusion-of-innovations theory to the examination of factors that are perceived by family physicians as influencing the implementation of electronic medical records (EMRs). Design Qualitative study with 2 focus groups 18 months after EMR implementation; participants also took part in a concurrent quantitative study examining EMR implementation and preventive services. Setting Toronto, Ont. Participants Twelve community-based family physicians. Methods We employed a semistructured interview guide. The interviews were audiotaped and transcribed verbatim; 2 researchers independently categorized and coded the transcripts and then met to compare and contrast their findings, category mapping, and interpretations. Findings were then mapped to an existing theoretical framework. Main findings Multiple barriers to EMR implementation were described. These included lack of relative advantage for many processes, high complexity of the system, low compatibility with physician needs and past experiences, difficulty with adaptation of the EMR to the organization and adaptation of the organization to the EMR, and lack of organizational slack. Positive factors were the presence of a champion and relative advantages for some processes. Conclusion Early EMR implementation experience is consistent with theoretical concepts associated with implementation of innovations. A problematic implementation process helps to explain, at least in part, the lack of improvement in preventive services in our quantitative results. PMID:21998247

  19. Basic Workshops for Medical Record Clerical Personnel.

    ERIC Educational Resources Information Center

    Intermountain Regional Medical Program, Salt Lake City, UT.

    This curriculum guide is an outline of the content for basic workshop training sessions of hospital medical record personnel. Following a two-page topical outline of five content areas, there is a detailed presentation of this content as follows: (1) the medical record and its contribution to patient care (Joint Commission for Accreditation of…

  20. [Patients' access to their medical records].

    PubMed

    Laranjo, Liliana; Neves, Ana Luisa; Villanueva, Tiago; Cruz, Jorge; Brito de Sá, Armando; Sakellarides, Constantitno

    2013-01-01

    Until recently, the medical record was seen exclusively as being the property of health institutions and doctors. Its great technical and scientific components, as well as the personal characteristics attributed by each doctor, have been the reasons appointed for that control. However, nowadays throughout the world that paradigm has been changing. In Portugal, since 2007 patients are allowed full and direct access to their medical records. Nevertheless, the Deontological Code of the Portuguese Medical Association (2009) explicitly states that patients' access to their medical records should have a doctor as intermediary and that the records are each physician's intellectual property. Furthermore, several doctors and health institutions, receiving requests from patients to access their medical records, end up requesting the legal opinion of the Commission for access to administrative documents. Each and every time, that opinion goes in line with the notion of full and direct patient access. Sharing medical records with patients seems crucial and inevitable in the current patient-centred care model, having the potential to improve patient empowerment, health literacy, autonomy, self-efficacy and satisfaction with care. With the recent technological developments and the fast dissemination of Personal Health Records, it is foreseeable that a growing number of patients will want to access their medical records. Therefore, promoting awareness on this topic is essential, in order to allow an informed debate between all the stakeholders. PMID:23815842

  1. Medical records and issues in negligence.

    PubMed

    Thomas, Joseph

    2009-07-01

    It is very important for the treating doctor to properly document the management of a patient under his care. Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the treatment was carried out properly. Moreover, it will also be of immense help in the scientific evaluation and review of patient management issues. Medical records form an important part of the management of a patient. It is important for the doctors and medical establishments to properly maintain the records of patients for two important reasons. The first one is that it will help them in the scientific evaluation of their patient profile, helping in analyzing the treatment results, and to plan treatment protocols. It also helps in planning governmental strategies for future medical care. But of equal importance in the present setting is in the issue of alleged medical negligence. The legal system relies mainly on documentary evidence in a situation where medical negligence is alleged by the patient or the relatives. In an accusation of negligence, this is very often the most important evidence deciding on the sentencing or acquittal of the doctor. With the increasing use of medical insurance for treatment, the insurance companies also require proper record keeping to prove the patient's demand for medical expenses. Improper record keeping can result in declining medical claims. It is disheartening to note that inspite of knowing the importance of proper record keeping it is still in a nascent stage in India. It is wise to remember that "Poor records mean poor defense, no records mean no defense". Medical records include a variety of documentation of patient's history, clinical findings, diagnostic test results, preoperative care, operation notes, post operative care, and daily notes of a patient's progress and medications. A properly obtained consent will go a long way in proving that the procedures were conducted with the concurrence of

  2. Automation of the Problem Oriented Medical Record

    NASA Technical Reports Server (NTRS)

    Schall, D. W.

    1971-01-01

    An improved ambulatory care delivery system developed for the Navy is examined. The system is centered around the concepts of problem oriented medical records and expanded use of paramedical personnel.

  3. Linking medical records to an expert system

    NASA Technical Reports Server (NTRS)

    Naeymi-Rad, Frank; Trace, David; Desouzaalmeida, Fabio

    1991-01-01

    This presentation will be done using the IMR-Entry (Intelligent Medical Record Entry) system. IMR-Entry is a software program developed as a front-end to our diagnostic consultant software MEDAS (Medical Emergency Decision Assistance System). MEDAS (the Medical Emergency Diagnostic Assistance System) is a diagnostic consultant system using a multimembership Bayesian design for its inference engine and relational database technology for its knowledge base maintenance. Research on MEDAS began at the University of Southern California and the Institute of Critical Care in the mid 1970's with support from NASA and NSF. The MEDAS project moved to Chicago in 1982; its current progress is due to collaboration between Illinois Institute of Technology, The Chicago Medical School, Lake Forest College and NASA at KSC. Since the purpose of an expert system is to derive a hypothesis, its communication vocabulary is limited to features used by its knowledge base. The development of a comprehensive problem based medical record entry system which could handshake with an expert system while creating an electronic medical record at the same time was studied. IMR-E is a computer based patient record that serves as a front end to the expert system MEDAS. IMR-E is a graphically oriented comprehensive medical record. The programs major components are demonstrated.

  4. Access to Personal Medical Records.

    ERIC Educational Resources Information Center

    Weisenstein, Sharon

    Whether individuals should be allowed to see and correct their health records evokes controversy that revolves about citizens' rights to know what information is kept on them, society's duty to protect individuals' and doctors' rights, and the rights of employers and other parties to maintain the confidentiality of their files. A review of the…

  5. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2012-07-01 2012-07-01 false Medical records. 17.905 Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina Bifida and Covered Birth Defects §...

  6. The Medical Record Review and Resident Education

    ERIC Educational Resources Information Center

    Schuller, Arthur B.; Stotz, Ronald

    1977-01-01

    With data from mother-infant pairs during the puerperium as an example, three possibilities for using the medical record review are discussed: (1) as a means of specifying objectives for patient care and trainee competence; (2) for assessing trainee progress and teaching program effectiveness; and (3) for assessing the effects of medical science…

  7. The Electronic Medical Record: Promises and Problems.

    ERIC Educational Resources Information Center

    Hersh, William R.

    1995-01-01

    Describes the state of electronic medical records, their advantage over existing paper records, the problems impeding their implementation, and concerns over their security and confidentiality. Topics include challenges for the new health care era, including managed care systems, cost benefits, lack of standards, and future possibilities.…

  8. 3 Steps to Building a Personal Medical Record

    MedlinePlus

    ... Building a Personal Medical Record Print to PDF 3 Steps to Building a Personal Medical Record August ... forms or make phone calls for you. Step 3. Organizing and storing your personal medical record There ...

  9. Privacy, confidentiality, and electronic medical records.

    PubMed Central

    Barrows, R C; Clayton, P D

    1996-01-01

    The enhanced availability of health information in an electronic format is strategic for industry-wide efforts to improve the quality and reduce the cost of health care, yet it brings a concomitant concern of greater risk for loss of privacy among health care participants. The authors review the conflicting goals of accessibility and security for electronic medical records and discuss nontechnical and technical aspects that constitute a reasonable security solution. It is argued that with guiding policy and current technology, an electronic medical record may offer better security than a traditional paper record. PMID:8653450

  10. Consultation of medical narratives in the electronic medical record.

    PubMed

    Tange, H J

    1999-12-01

    This article presents an overview of a research project concerning the consultation of medical narratives in the electronic medical record (EMR). It describes an analysis of user needs, the design and implementation of a prototype EMR system, and the evaluation of the ease of consultation of medical narratives when using this system. In a questionnaire survey, 85 hospital physicians judged the quality of their paper-based medical record with respect to data entry, information retrieval and some other aspects. Participants were more positive about the paper medical record than the literature suggests. They wished to maintain the flexibility of data entry but indicated the need to improve the retrieval of information. A prototype EMR system was developed to facilitate the consultation of medical narratives. These parts were divided into labeled segments that could be arranged source-oriented and problem-oriented. This system was used to evaluate the ease of information retrieval of 24 internists and 12 residents at a teaching hospital when using free-text medical narratives divided at different levels of detail. They solved, without time pressure, some predefined problems concerning three voluminous, inpatient case records. The participants were randomly allocated to a sequence that was balanced by patient case and learning effect. The division of medical narratives affected speed, but not completeness of information retrieval. Progress notes divided into problem-related segments could be consulted 22% faster than when undivided. Medical history and physical examination divided into segments at organ-system level could be consulted 13% faster than when divided into separate questions and observations. These differences were statistically significant. The fastest divisions were also appreciated as the best combination of easy searching and best insight in the patient case. The results of our evaluation study suggest a trade-off between searching and reading: too much

  11. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... Special procedures: Medical records. (a) No response to any request for access to medical records by an... routine use, for all systems of records containing medical records, consultations with an individual's... every case of a request by an individual for access to medical records, the Privacy Officer shall:...

  12. Medical Terminology of the Musculoskeletal System. Medical Records. Instructional Unit for the Medical Transcriber.

    ERIC Educational Resources Information Center

    Gosman, Minna L.

    Following an analysis of the task of transcribing as practiced in a health facility, this study guide was developed to teach the knowledge and skills required of a medical transcriber. The medical record department was identified as a major occupational area, and a task inventory for medical records was developed and used as a basis for a…

  13. Medical Terminology of the Circulatory System. Medical Records. Instructional Unit for the Medical Transcriber.

    ERIC Educational Resources Information Center

    Gosman, Minna L.

    Developed as a result of an analysis of the task of transcribing as practiced in a health facility, this study guide was designed to teach the knowledge and skills required of a medical transcriber. The medical record department was identified as a major occupational area, and a task inventory for medical records was developed and used as a basis…

  14. 20 CFR 401.55 - Access to medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... _____'s (Name of minor) medical records. Please be informed that if any medical record was found... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false Access to medical records. 401.55 Section 401... INFORMATION The Privacy Act § 401.55 Access to medical records. (a) General. You have a right to access...

  15. 20 CFR 401.55 - Access to medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... _____'s (Name of minor) medical records. Please be informed that if any medical record was found... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false Access to medical records. 401.55 Section 401... INFORMATION The Privacy Act § 401.55 Access to medical records. (a) General. You have a right to access...

  16. 20 CFR 401.55 - Access to medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... _____'s (Name of minor) medical records. Please be informed that if any medical record was found... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false Access to medical records. 401.55 Section 401... INFORMATION The Privacy Act § 401.55 Access to medical records. (a) General. You have a right to access...

  17. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2010-07-01 2010-07-01 false Special procedures: Medical... Special procedures: Medical records. (a) No response to any request for access to medical records by an... routine use, for all systems of records containing medical records, consultations with an...

  18. 20 CFR 401.55 - Access to medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false Access to medical records. 401.55 Section 401... INFORMATION The Privacy Act § 401.55 Access to medical records. (a) General. You have a right to access your medical records, including any psychological information that we maintain. (b) Medical records...

  19. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2014-07-01 2014-07-01 false Special procedures: Medical... Special procedures: Medical records. (a) No response to any request for access to medical records by an... routine use, for all systems of records containing medical records, consultations with an...

  20. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Medical magnetic tape recorder. 870.2800 Section... (CONTINUED) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Monitoring Devices § 870.2800 Medical magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  1. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Medical magnetic tape recorder. 870.2800 Section... (CONTINUED) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Monitoring Devices § 870.2800 Medical magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  2. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2012-07-01 2012-07-01 false Special procedures: Medical... Special procedures: Medical records. (a) No response to any request for access to medical records by an... routine use, for all systems of records containing medical records, consultations with an...

  3. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... information to a medical doctor named by the requesting individual for release of the patient....

  4. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... information to a medical doctor named by the requesting individual for release of the patient....

  5. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... information to a medical doctor named by the requesting individual for release of the patient....

  6. Intelligent consumer-centric electronic medical record.

    PubMed

    Luo, Gang; Thomas, Selena B; Tang, Chunqiang

    2009-01-01

    Web-based, consumer-centric electronic medical records (CEMRs) are currently undergoing widespread deployment. Existing CEMRs, however, have limited intelligence and cannot satisfy users' many needs. This paper proposes the concept of intelligent CEMR. We introduce and extend expert system and web search technology into the CEMR domain. The resulting intelligent CEMRs can automatically provide users with personalized healthcare information to facilitate their daily activities. We use automatic home medical product recommendation as a concrete application to demonstrate the benefits offered by intelligent CEMRs. PMID:19745280

  7. Recent perspectives of electronic medical record systems

    PubMed Central

    ZHANG, XIAO-YING; ZHANG, PEIYING

    2016-01-01

    Implementation of electronic medical record (EMR) systems within developing contexts as part of efforts to monitor and facilitate the attainment of health-related aims has been on the increase. However, these efforts have been concentrated on urban hospitals. Recent findings showed that development processes of EMR systems are associated with various discrepancies between protocols and work practices. These discrepancies were mainly caused by factors including high workload, lack of medical resources, misunderstanding of the protocols by health workers, and client/patient practices. The present review focused on the effects of EMRs on patient care work, and on appropriate EMR designs principles and strategies to ameliorate these systems. PMID:27284289

  8. Electronic medical records and quality improvement.

    PubMed

    Carter, Jonathan T

    2015-04-01

    Widespread adoption of electronic medical records (EMRs) in the United States is transforming the practice of medicine from a paper-based cottage industry into an integrated health care delivery system. Most physicians and institutions view the widespread use of EMRs to be inevitable. But the transformation has not been painless. Many have questioned whether the substantial investment in electronic health records has really been justified by improved patient outcomes or quality of care. This article describes historical and recent efforts to use EMRs to improve the quality of patient care, and provides a roadmap of EMR uses for the foreseeable future. PMID:25771280

  9. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 5 2012-01-01 2012-01-01 false Special procedures: Medical records. 310.6... PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on... transmission of the medical information directly to the requesting individual could have an adverse effect...

  10. Electronic medical record and glaucoma medications: connecting the medication reconciliation with adherence

    PubMed Central

    Bacon, Thomas S; Fan, Kenneth C; Desai, Manishi A

    2016-01-01

    Purpose To evaluate consistency in documentation of glaucoma medications in the electronic medical record and identify which regimen patients adhere to when inconsistencies exist. Factors contributing to medication nonadherence are also explored. Methods Retrospective chart review of medication adherence encompassing 200 patients from three glaucoma physicians at a tertiary referral center over a 1-month period. Adherence was determined by the consistency between a patients stated medication regimen and either the active medication list in the electronic medical record, or the physicians planned medication regimen in the preceding clinic visit. Patient charts were also reviewed for patient sex, age, primary language, race, and total number of medications. Results A total of 160 charts showed consistency in documentation between the physician note and electronic medication reconciliation. Of those patients, 83.1% reported adherence with their glaucoma medication schedule. When there was a discrepancy in documentation (40 charts), 72.5% patients followed the physician-stated regimen vs 20% who followed neither vs 7.5% who followed the medical record (P<0.01). No difference in adherence was observed based on sex (P=0.912) or total number of medications taken (P=0.242). Language, both English- (P=0.075) and Haitian (P=0.10) -speaking populations, as well as race, Caucasian (P=0.31), African-American (P=0.54), and Hispanic (P=0.58), had no impact on medication adherence. Patients over 80 years of age were more nonadherent as compared to other decades (P=0.04). Conclusion Inconsistent documentation between the electronic medical record physician note and medication regimen may contribute to patient medication nonadherence. Patients over 80 years of age were associated with higher rates of nonadherence, while sex, total number of medications, race, and language had no interaction with medication adherence. PMID:26869756

  11. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... medical records. 6.31 Section 6.31 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY... Records § 6.31 Special requirements for medical records. (a) A system manager who receives a request from an individual for access to those official medical records which belong to the U.S. Office...

  12. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 4 2010-07-01 2010-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  13. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 7 Agriculture 1 2010-01-01 2010-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  14. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 7 Agriculture 1 2011-01-01 2011-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  15. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... medical records. 6.31 Section 6.31 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY... Records § 6.31 Special requirements for medical records. (a) A system manager who receives a request from an individual for access to those official medical records which belong to the U.S. Office...

  16. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 4 2012-01-01 2012-01-01 false Special procedures for medical records. 261a.7... Procedures for Requests by Individuals to Whom Record Pertains § 261a.7 Special procedures for medical records. If you request medical or psychological records pursuant to § 261a.5, we will disclose...

  17. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 4 2013-01-01 2013-01-01 false Special procedures for medical records. 261a.7... Procedures for Requests by Individuals to Whom Record Pertains § 261a.7 Special procedures for medical records. If you request medical or psychological records pursuant to § 261a.5, we will disclose...

  18. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 40 Protection of Environment 1 2012-07-01 2012-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  19. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 29 Labor 4 2013-07-01 2013-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  20. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... medical records. 6.31 Section 6.31 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY... Records § 6.31 Special requirements for medical records. (a) A system manager who receives a request from an individual for access to those official medical records which belong to the U.S. Office...

  1. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  2. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 1 2010-01-01 2010-01-01 false Access to medical records. 297.205... PROCEDURES FOR PERSONNEL RECORDS Request for Access § 297.205 Access to medical records. When a request for access involves medical or psychological records that the system manager believes requires...

  3. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 5 Administrative Personnel 1 2012-01-01 2012-01-01 false Access to medical records. 297.205... PROCEDURES FOR PERSONNEL RECORDS Request for Access § 297.205 Access to medical records. When a request for access involves medical or psychological records that the system manager believes requires...

  4. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... medical records. 6.31 Section 6.31 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY... Records § 6.31 Special requirements for medical records. (a) A system manager who receives a request from an individual for access to those official medical records which belong to the U.S. Office...

  5. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... Requests by Individuals to Whom Record Pertains § 261a.7 Special procedures for medical records. If you request medical or psychological records pursuant to § 261a.5, we will disclose them directly to you... 12 Banks and Banking 3 2011-01-01 2011-01-01 false Special procedures for medical records....

  6. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 12 Banks and Banking 4 2014-01-01 2014-01-01 false Special procedures for medical records. 261a.7... Procedures for Requests by Individuals to Whom Record Pertains § 261a.7 Special procedures for medical records. If you request medical or psychological records pursuant to § 261a.5, we will disclose...

  7. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 7 Agriculture 1 2012-01-01 2012-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  8. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 40 Protection of Environment 1 2011-07-01 2011-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  9. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  10. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 4 2011-07-01 2011-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  11. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 40 Protection of Environment 1 2013-07-01 2013-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  12. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  13. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  14. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 5 Administrative Personnel 1 2011-01-01 2011-01-01 false Access to medical records. 297.205... PROCEDURES FOR PERSONNEL RECORDS Request for Access § 297.205 Access to medical records. When a request for access involves medical or psychological records that the system manager believes requires...

  15. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 40 Protection of Environment 1 2014-07-01 2014-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  16. 40 CFR 16.8 - Special procedures: Medical Records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 40 Protection of Environment 1 2010-07-01 2010-07-01 false Special procedures: Medical Records. 16... PRIVACY ACT OF 1974 § 16.8 Special procedures: Medical Records. Should EPA receive a request for access to medical records (including psychological records) disclosure of which the system manager decides would...

  17. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 29 Labor 4 2014-07-01 2014-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  18. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 7 Agriculture 1 2013-01-01 2013-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  19. 7 CFR 1.115 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 7 Agriculture 1 2014-01-01 2014-01-01 false Special procedures: Medical records. 1.115 Section 1... Regulations § 1.115 Special procedures: Medical records. In the event an agency receives a request pursuant to § 1.112 for access to medical records (including psychological records) whose disclosure it...

  20. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 1 2013-01-01 2013-01-01 false Access to medical records. 297.205... PROCEDURES FOR PERSONNEL RECORDS Request for Access § 297.205 Access to medical records. When a request for access involves medical or psychological records that the system manager believes requires...

  1. 29 CFR 1611.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 29 Labor 4 2012-07-01 2012-07-01 false Special procedures: Medical records. 1611.6 Section 1611.6... REGULATIONS § 1611.6 Special procedures: Medical records. In the event the Commission receives a request pursuant to § 1611.3 for access to medical records (including psychological records) whose disclosure...

  2. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ...-medical records. 1301.16 Section 1301.16 Conservation of Power and Water Resources TENNESSEE VALLEY AUTHORITY PROCEDURES Privacy Act § 1301.16 Special procedures—medical records. If, in the judgment of TVA, the transmission of medical records, including psychological records, directly to a...

  3. Medical records in family practice. A review.

    PubMed

    Warren, M D

    1976-01-01

    The organisation of general practice in England is outlined and the independent contractor basis of the family practioner emphasised. Data from family practice, like data from hospital practice, may be used for clinical management, practice management, or research. Examples of applications in each of these fields are given. The basic records used in family practice--the medical record envelope, the prescription form and the claim for sickness benefit--are described. Some practices record morbidity (E Book or Diagnostic Index), some record systematically details of their activities (L Book or Activities Ledger) and some maintain age and sex registers and other registers of their patients; all these developments are outlined. Attention is drawn to the introduction of problem orientated records and to the use of computers in family practice, but these innovations are not discussed. Outstanding issues are the same as those in hospital record systems--accuracy, definitions, coverage, confidentiality, clerical support and costs, and the use made of the information. PMID:1085489

  4. 11 CFR 1.6 - Special procedure: Medical records. [Reserved

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 11 Federal Elections 1 2013-01-01 2012-01-01 true Special procedure: Medical records. 1.6 Section 1.6 Federal Elections FEDERAL ELECTION COMMISSION PRIVACY ACT § 1.6 Special procedure: Medical records....

  5. 11 CFR 1.6 - Special procedure: Medical records. [Reserved

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 11 Federal Elections 1 2012-01-01 2012-01-01 false Special procedure: Medical records. 1.6 Section 1.6 Federal Elections FEDERAL ELECTION COMMISSION PRIVACY ACT § 1.6 Special procedure: Medical records....

  6. 11 CFR 1.6 - Special procedure: Medical records. [Reserved

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 11 Federal Elections 1 2014-01-01 2014-01-01 false Special procedure: Medical records. 1.6 Section 1.6 Federal Elections FEDERAL ELECTION COMMISSION PRIVACY ACT § 1.6 Special procedure: Medical records....

  7. 11 CFR 1.6 - Special procedure: Medical records. [Reserved

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 11 Federal Elections 1 2011-01-01 2011-01-01 false Special procedure: Medical records. 1.6 Section 1.6 Federal Elections FEDERAL ELECTION COMMISSION PRIVACY ACT § 1.6 Special procedure: Medical records....

  8. 11 CFR 1.6 - Special procedure: Medical records. [Reserved

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 11 Federal Elections 1 2010-01-01 2010-01-01 false Special procedure: Medical records. 1.6 Section 1.6 Federal Elections FEDERAL ELECTION COMMISSION PRIVACY ACT § 1.6 Special procedure: Medical records....

  9. 49 CFR 386.48 - Medical records and physicians' reports.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 49 Transportation 5 2010-10-01 2010-10-01 false Medical records and physicians' reports. 386.48... HAZARDOUS MATERIALS PROCEEDINGS General Rules and Hearings § 386.48 Medical records and physicians' reports... results, and other medical records that a party intends to rely upon shall be served on all other...

  10. 5 CFR 2504.6 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Special procedures for medical records... PRESIDENT PRIVACY ACT REGULATIONS § 2504.6 Special procedures for medical records. (a) When the Privacy Act Officer receives a request from an individual for access to those official medical records which belong...

  11. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 4 2010-07-01 2010-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  12. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 15 Commerce and Foreign Trade 1 2010-01-01 2010-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  13. 12 CFR 310.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 5 2013-01-01 2013-01-01 false Special procedures: Medical records. 310.6 Section 310.6 Banks and Banking FEDERAL DEPOSIT INSURANCE CORPORATION PROCEDURE AND RULES OF PRACTICE PRIVACY ACT REGULATIONS § 310.6 Special procedures: Medical records. Medical records shall be disclosed on request to the individuals to whom...

  14. 12 CFR 1403.6 - Special procedures for medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 9 2012-01-01 2012-01-01 false Special procedures for medical records. 1403.6 Section 1403.6 Banks and Banking FARM CREDIT SYSTEM INSURANCE CORPORATION PRIVACY ACT REGULATIONS § 1403.6 Special procedures for medical records. Medical records in the custody of the Farm Credit System...

  15. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 15 Commerce and Foreign Trade 1 2012-01-01 2012-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  16. 12 CFR 603.325 - Special procedures for medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 7 2012-01-01 2012-01-01 false Special procedures for medical records. 603.325 Section 603.325 Banks and Banking FARM CREDIT ADMINISTRATION ADMINISTRATIVE PROVISIONS PRIVACY ACT REGULATIONS § 603.325 Special procedures for medical records. Medical records in the custody of the...

  17. 12 CFR 1403.6 - Special procedures for medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 9 2013-01-01 2013-01-01 false Special procedures for medical records. 1403.6 Section 1403.6 Banks and Banking FARM CREDIT SYSTEM INSURANCE CORPORATION PRIVACY ACT REGULATIONS § 1403.6 Special procedures for medical records. Medical records in the custody of the Farm Credit System...

  18. 49 CFR 386.48 - Medical records and physicians' reports.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 49 Transportation 5 2014-10-01 2014-10-01 false Medical records and physicians' reports. 386.48... HAZARDOUS MATERIALS PROCEEDINGS General Rules and Hearings § 386.48 Medical records and physicians' reports... results, and other medical records that a party intends to rely upon shall be served on all other...

  19. 49 CFR 386.48 - Medical records and physicians' reports.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 49 Transportation 5 2011-10-01 2011-10-01 false Medical records and physicians' reports. 386.48... HAZARDOUS MATERIALS PROCEEDINGS General Rules and Hearings § 386.48 Medical records and physicians' reports... results, and other medical records that a party intends to rely upon shall be served on all other...

  20. 12 CFR 603.325 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Special procedures for medical records. 603.325 Section 603.325 Banks and Banking FARM CREDIT ADMINISTRATION ADMINISTRATIVE PROVISIONS PRIVACY ACT REGULATIONS § 603.325 Special procedures for medical records. Medical records in the custody of the...

  1. 12 CFR 603.325 - Special procedures for medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 12 Banks and Banking 7 2014-01-01 2014-01-01 false Special procedures for medical records. 603.325 Section 603.325 Banks and Banking FARM CREDIT ADMINISTRATION ADMINISTRATIVE PROVISIONS PRIVACY ACT REGULATIONS § 603.325 Special procedures for medical records. Medical records in the custody of the...

  2. 5 CFR 2504.6 - Special procedures for medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 5 Administrative Personnel 3 2011-01-01 2011-01-01 false Special procedures for medical records... PRESIDENT PRIVACY ACT REGULATIONS § 2504.6 Special procedures for medical records. (a) When the Privacy Act Officer receives a request from an individual for access to those official medical records which belong...

  3. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 29 Labor 4 2013-07-01 2013-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  4. 12 CFR 1070.55 - Special procedures for medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 8 2012-01-01 2012-01-01 false Special procedures for medical records. 1070.55... INFORMATION The Privacy Act § 1070.55 Special procedures for medical records. If an individual requests medical or psychological records pursuant to § 1070.53 of this subpart, the CFPB will disclose...

  5. 5 CFR 2504.6 - Special procedures for medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 5 Administrative Personnel 3 2012-01-01 2012-01-01 false Special procedures for medical records... PRESIDENT PRIVACY ACT REGULATIONS § 2504.6 Special procedures for medical records. (a) When the Privacy Act Officer receives a request from an individual for access to those official medical records which belong...

  6. 12 CFR 261a.7 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... Requests by Individual to Whom Record Pertains § 261a.7 Special procedures for medical records. Medical or... 12 Banks and Banking 3 2010-01-01 2010-01-01 false Special procedures for medical records. 261a.7 Section 261a.7 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE...

  7. 12 CFR 603.325 - Special procedures for medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 7 2013-01-01 2013-01-01 false Special procedures for medical records. 603.325 Section 603.325 Banks and Banking FARM CREDIT ADMINISTRATION ADMINISTRATIVE PROVISIONS PRIVACY ACT REGULATIONS § 603.325 Special procedures for medical records. Medical records in the custody of the...

  8. 12 CFR 1070.55 - Special procedures for medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 12 Banks and Banking 9 2014-01-01 2014-01-01 false Special procedures for medical records. 1070.55... INFORMATION The Privacy Act § 1070.55 Special procedures for medical records. If an individual requests medical or psychological records pursuant to § 1070.53 of this subpart, the CFPB will disclose...

  9. 5 CFR 2504.6 - Special procedures for medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 3 2013-01-01 2013-01-01 false Special procedures for medical records... PRESIDENT PRIVACY ACT REGULATIONS § 2504.6 Special procedures for medical records. (a) When the Privacy Act Officer receives a request from an individual for access to those official medical records which belong...

  10. 5 CFR 297.205 - Access to medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 5 Administrative Personnel 1 2014-01-01 2014-01-01 false Access to medical records. 297.205 Section 297.205 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT CIVIL SERVICE REGULATIONS PRIVACY PROCEDURES FOR PERSONNEL RECORDS Request for Access § 297.205 Access to medical records. When a request for access involves medical or...

  11. 12 CFR 1070.55 - Special procedures for medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 12 Banks and Banking 8 2013-01-01 2013-01-01 false Special procedures for medical records. 1070.55... INFORMATION The Privacy Act § 1070.55 Special procedures for medical records. If an individual requests medical or psychological records pursuant to § 1070.53 of this subpart, the CFPB will disclose...

  12. 12 CFR 1403.6 - Special procedures for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 7 2010-01-01 2010-01-01 false Special procedures for medical records. 1403.6 Section 1403.6 Banks and Banking FARM CREDIT SYSTEM INSURANCE CORPORATION PRIVACY ACT REGULATIONS § 1403.6 Special procedures for medical records. Medical records in the custody of the Farm Credit System...

  13. 12 CFR 1403.6 - Special procedures for medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 12 Banks and Banking 10 2014-01-01 2014-01-01 false Special procedures for medical records. 1403.6 Section 1403.6 Banks and Banking FARM CREDIT SYSTEM INSURANCE CORPORATION PRIVACY ACT REGULATIONS § 1403.6 Special procedures for medical records. Medical records in the custody of the Farm Credit System Insurance Corporation which are not...

  14. 12 CFR 1403.6 - Special procedures for medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 12 Banks and Banking 7 2011-01-01 2011-01-01 false Special procedures for medical records. 1403.6 Section 1403.6 Banks and Banking FARM CREDIT SYSTEM INSURANCE CORPORATION PRIVACY ACT REGULATIONS § 1403.6 Special procedures for medical records. Medical records in the custody of the Farm Credit System...

  15. 49 CFR 386.48 - Medical records and physicians' reports.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 49 Transportation 5 2012-10-01 2012-10-01 false Medical records and physicians' reports. 386.48... HAZARDOUS MATERIALS PROCEEDINGS General Rules and Hearings § 386.48 Medical records and physicians' reports... results, and other medical records that a party intends to rely upon shall be served on all other...

  16. 12 CFR 603.325 - Special procedures for medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 12 Banks and Banking 6 2011-01-01 2011-01-01 false Special procedures for medical records. 603.325 Section 603.325 Banks and Banking FARM CREDIT ADMINISTRATION ADMINISTRATIVE PROVISIONS PRIVACY ACT REGULATIONS § 603.325 Special procedures for medical records. Medical records in the custody of the...

  17. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 15 Commerce and Foreign Trade 1 2013-01-01 2013-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  18. 49 CFR 386.48 - Medical records and physicians' reports.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 49 Transportation 5 2013-10-01 2013-10-01 false Medical records and physicians' reports. 386.48... HAZARDOUS MATERIALS PROCEEDINGS General Rules and Hearings § 386.48 Medical records and physicians' reports... results, and other medical records that a party intends to rely upon shall be served on all other...

  19. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 37 Patents, Trademarks, and Copyrights 1 2011-07-01 2011-07-01 false Special procedures: Medical records. 102.26 Section 102.26 Patents, Trademarks, and Copyrights UNITED STATES PATENT AND TRADEMARK... Special procedures: Medical records. (a) No response to any request for access to medical records by...

  20. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 15 Commerce and Foreign Trade 1 2011-01-01 2011-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  1. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 5 Administrative Personnel 3 2011-01-01 2011-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  2. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 4 2011-07-01 2011-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  3. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 5 Administrative Personnel 3 2013-01-01 2013-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  4. 17 CFR 200.305 - Special procedure: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 17 Commodity and Securities Exchanges 2 2010-04-01 2010-04-01 false Special procedure: Medical... Individuals and Systems of Records Maintained by the Commission § 200.305 Special procedure: Medical records... records pertaining to him that include medical and/or psychological information, the Commission, if...

  5. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ...: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An individual requesting disclosure of a record which contains medical or psychological information may name a...

  6. 17 CFR 200.305 - Special procedure: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 17 Commodity and Securities Exchanges 2 2013-04-01 2013-04-01 false Special procedure: Medical... Individuals and Systems of Records Maintained by the Commission § 200.305 Special procedure: Medical records... records pertaining to him that include medical and/or psychological information, the Commission, if...

  7. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 5 Administrative Personnel 3 2014-01-01 2014-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  8. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 29 Labor 4 2012-07-01 2012-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  9. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ...: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An individual requesting disclosure of a record which contains medical or psychological information may name a...

  10. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  11. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 2 2013-07-01 2013-07-01 false Special procedures: Medical records. 319.7... (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures: Medical records. Medical records, requested pursuant to § 319.5 of this part, will be disclosed to the...

  12. 29 CFR 1410.5 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 29 Labor 4 2014-07-01 2014-07-01 false Special procedures: Medical records. 1410.5 Section 1410.5 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE PRIVACY § 1410.5 Special procedures: Medical records. (a) If medical records are requested for inspection...

  13. 5 CFR 2412.7 - Special procedures; medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 5 Administrative Personnel 3 2012-01-01 2012-01-01 false Special procedures; medical records. 2412.7 Section 2412.7 Administrative Personnel FEDERAL LABOR RELATIONS AUTHORITY, GENERAL COUNSEL OF THE... Special procedures; medical records. (a) If medical records are requested for inspection which, in...

  14. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ...: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An individual requesting disclosure of a record which contains medical or psychological information may name a...

  15. 15 CFR 4.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 15 Commerce and Foreign Trade 1 2014-01-01 2014-01-01 false Special procedures: Medical records. 4... GOVERNMENT INFORMATION Privacy Act § 4.26 Special procedures: Medical records. (a) No response to any request for access to medical records from an individual will be issued by the Privacy Officer for a period...

  16. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ...: Medical records. 701.306 Section 701.306 Conservation of Power and Water Resources WATER RESOURCES COUNCIL COUNCIL ORGANIZATION Protection of Privacy § 701.306 Special procedure: Medical records. (a) An individual requesting disclosure of a record which contains medical or psychological information may name a...

  17. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 2 2011-07-01 2011-07-01 false Special procedures: Medical records. 319.7... (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures: Medical records. Medical records, requested pursuant to § 319.5 of this part, will be disclosed to the...

  18. The CRABEL score--a method for auditing medical records.

    PubMed Central

    Crawford, J. R.; Beresford, T. P.; Lafferty, K. L.

    2001-01-01

    Medical record keeping has become increasingly important particularly for research, audit and medico-legal purposes. The authors present a protocol, the CRABEL score, that is quick and easy to use for the assessment of the quality of medical record keeping with the purpose of standardizing the audit of medical records and improving their quality. PMID:11212456

  19. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 10 Energy 1 2011-01-01 2011-01-01 false Records of mobile medical services. 35.2080 Section 35.2080 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2080 Records of mobile medical services. (a) A licensee shall retain a copy of each letter that permits the use...

  20. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Records of mobile medical services. 35.2080 Section 35.2080 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2080 Records of mobile medical services. (a) A licensee shall retain a copy of each letter that permits the use...

  1. Essentials of an Acceptable School for Medical Record Technicians.

    ERIC Educational Resources Information Center

    American Medical Association, Chicago, IL. Council on Medical Education.

    The Council on Medical Education of the American Medical Association in collaboration with the American Association of Medical Record Librarians establishes standards for medical record technician education, surveys and approves educational programs, and publishes lists of approved programs. The standards presented are intended as a guide for…

  2. Shallow medication extraction from hospital patient records.

    PubMed

    Boytcheva, Svetla

    2011-01-01

    This paper presents methods for shallow Information Extraction (IE) from the free text zones of hospital Patient Records (PRs) in Bulgarian language in the Patient Safety through Intelligent Procedures in medication (PSIP) project. We extract automatically information about drug names, dosage, modes and frequency and assign the corresponding ATC code to each medication event. Using various modules for rule-based text analysis, our IE components in PSIP perform a significant amount of symbolic computations. We try to address negative statements, elliptical constructions, typical conjunctive phrases, and simple inferences concerning temporal constraints and finally aim at the assignment of the drug ACT code to the extracted medication events, which additionally complicates the extraction algorithm. The prototype of the system was used for experiments with a training corpus containing 1,300 PRs and the evaluation results are obtained using a test corpus containing 6,200 PRs. The extraction accuracy (f-score) for drug names is 98.42% and for dose 93.85%. PMID:21685617

  3. A benchmark comparison of deterministic and probabilistic methods for defining manual review datasets in duplicate records reconciliation

    PubMed Central

    Joffe, Erel; Byrne, Michael J; Reeder, Phillip; Herskovic, Jorge R; Johnson, Craig W; McCoy, Allison B; Sittig, Dean F; Bernstam, Elmer V

    2014-01-01

    Introduction Clinical databases require accurate entity resolution (ER). One approach is to use algorithms that assign questionable cases to manual review. Few studies have compared the performance of common algorithms for such a task. Furthermore, previous work has been limited by a lack of objective methods for setting algorithm parameters. We compared the performance of common ER algorithms: using algorithmic optimization, rather than manual parameter tuning, and on two-threshold classification (match/manual review/non-match) as well as single-threshold (match/non-match). Methods We manually reviewed 20 000 randomly selected, potential duplicate record-pairs to identify matches (10 000 training set, 10 000 test set). We evaluated the probabilistic expectation maximization, simple deterministic and fuzzy inference engine (FIE) algorithms. We used particle swarm to optimize algorithm parameters for a single and for two thresholds. We ran 10 iterations of optimization using the training set and report averaged performance against the test set. Results The overall estimated duplicate rate was 6%. FIE and simple deterministic algorithms allowed a lower manual review set compared to the probabilistic method (FIE 1.9%, simple deterministic 2.5%, probabilistic 3.6%; p<0.001). For a single threshold, the simple deterministic algorithm performed better than the probabilistic method (positive predictive value 0.956 vs 0.887, sensitivity 0.985 vs 0.887, p<0.001). ER with FIE classifies 98.1% of record-pairs correctly (1/10 000 error rate), assigning the remainder to manual review. Conclusions Optimized deterministic algorithms outperform the probabilistic method. There is a strong case for considering optimized deterministic methods for ER. PMID:23703827

  4. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 10 Energy 4 2012-01-01 2012-01-01 false Maintenance of medical records. 712.38 Section 712.38 Energy DEPARTMENT OF ENERGY HUMAN RELIABILITY PROGRAM Medical Standards § 712.38 Maintenance of medical records. (a) The medical records of HRP candidates and HRP-certified individuals must be maintained in accordance with the Privacy Act, 5 U.S.C....

  5. Video Recording Paper - Innovation In Medical Video Recording

    NASA Astrophysics Data System (ADS)

    Shalit, Hanoch

    1985-09-01

    Traditionally, multiple format recording emulsions for medical video imaging have utilized a film (transparent) base. The major reason for this is probably because the film and camera manufacturers felt the diagnostician is accustomed to viewing x-ray images on a film base and would prefer to view video images that way also. Because of the need to keep radiation exposure to patients at a minimum and the fact that photographic emulsions are generally very inefficient in utilizing x-ray radiation, a film base was the logical requirement for direct x-ray imaging as it enabled the image to be recorded by two emulsions rather than one. The transparent base thus allows viewing a photograph which is the result of the additive effect of the two emulsions. The use of transparent base imposed specific requirements that necessitated the development of a whole complex of equipment designed for the particular use of film such as the processing machines, their chemical solutions, and the famous viewbox and alternators that characterize the radiology departments of today.

  6. Progress in electronic medical record adoption in Canada

    PubMed Central

    Chang, Feng; Gupta, Nishi

    2015-01-01

    Objective To determine the rate of adoption of electronic medical records (EMRs) by physicians across Canada, provincial incentives, and perceived benefits of and barriers to EMR adoption. Data sources Data on EMR adoption in Canada were collected from CINAHL, MEDLINE, PubMed, EMBASE, the Cochrane Library, the Health Council of Canada, Canada Health Infoway, government websites, regional EMR associations, and health professional association websites. Study selection After removal of duplicate articles, 236 documents were found matching the original search. After using the filter Canada, 12 documents remained. Additional documents were obtained from each province’s EMR website and from the Canada Health Infoway website. Synthesis Since 2006, Canadian EMR adoption rates have increased from about 20% of practitioners to an estimated 62% of practitioners in 2013, with substantial regional disparities ranging from roughly 40% of physicians in New Brunswick and Quebec to more than 75% of physicians in Alberta. Provincial incentives vary widely but appear to have only a weak relationship with the rate of adoption. Many adopters use only a fraction of their software’s available functions. User-cited benefits to adoption include time savings, improved record keeping, heightened patient safety, and confidence in retrieved data when EMRs are used efficiently. Barriers to adoption include financial and time constraints, lack of knowledgeable support personnel, and lack of interoperability with hospital and pharmacy systems. Conclusion Canadian physicians remain at the stage of EMR adoption. Progression in EMR use requires experienced, knowledgeable technical support during implementation, and financial support for the transcription of patient data from paper to electronic media. The interoperability of EMR offerings for hospitals, pharmacies, and clinics is the rate-limiting factor in achieving a unified EMR solution for Canada. PMID:27035020

  7. Paperless medical records: reinventing the patient experience.

    PubMed

    Tobey, Mary Ellen

    2004-01-01

    At North Shore Magnetic Imaging Center, the patient paper medical record system was becoming very cumbersome, and it served as a source of frustration for everyone involved: patients, technologists, radiologists, and staff members. The center's mapping of a typical patient experience indicated that, from the initial phone call scheduling an exam to a completed visit (claim processed and payment received), a record could be handled by as many as 20 sets of hands! In June 2002, the center's growth and a concern that patients were losing a one-on-one experience with the medical staff led to an evaluation of workflow processes existing at that time. The evaluation began with a survey of staff members, center management, radiologists, and referring physicians. Their responses indicated 3 common themes: stress, overload, and frustration over systems in place. Comments from the survey were grouped into 3 areas: Continue to Do, Stop Doing, and Start Doing. The Start Doing responses provided solid objectives. The center set out to establish a breakthrough project that included all stakeholders--patients, staff, management, and radiologists. The Reinvention Project had 2 primary goals: move to a paperless environment and increase the level of patient care. The project was divided into internal and external teams. The internal team, called the Reinvention Team, was responsible for the actual hands-on aspects of the process. There were numerous external teams; each had defined roles and specific outcomes for achievement. The external teams' responsibilities included implementing an Internet protocol telephone system; researching voice recognition; restructuring job descriptions, training manuals, and performance evaluations; and conducting a patient-centered focus group. PMID:15259685

  8. Building a national electronic medical record exchange system - experiences in Taiwan.

    PubMed

    Li, Yu-Chuan Jack; Yen, Ju-Chuan; Chiu, Wen-Ta; Jian, Wen-Shan; Syed-Abdul, Shabbir; Hsu, Min-Huei

    2015-08-01

    There are currently 501 hospitals and about 20,000 clinics in Taiwan. The National Health Insurance (NHI) system, which is operated by the NHI Administration, uses a single-payer system and covers 99.9% of the nation's total population of 23,000,000. Taiwan's NHI provides people with a high degree of freedom in choosing their medical care options. However, there is the potential concern that the available medical resources will be overused. The number of doctor consultations per person per year is about 15. Duplication of laboratory tests and prescriptions are not rare either. Building an electronic medical record exchange system is a good method of solving these problems and of improving continuity in health care. In November 2009, Taiwan's Executive Yuan passed the 'Plan for accelerating the implementation of electronic medical record systems in medical institutions' (2010-2012; a 3-year plan). According to this plan, a patient can, at any hospital in Taiwan, by using his/her health insurance IC card and physician's medical professional IC card, upon signing a written agreement, retrieve all important medical records for the past 6 months from other participating hospitals. The focus of this plan is to establish the National Electronic Medical Record Exchange Centre (EEC). A hospital's information system will be connected to the EEC through an electronic medical record (EMR) gateway. The hospital will convert the medical records for the past 6 months in its EMR system into standardized files and save them on the EMR gateway. The most important functions of the EEC are to generate an index of all the XML files on the EMR gateways of all hospitals, and to provide search and retrieval services for hospitals and clinics. The EEC provides four standard inter-institution EMR retrieval services covering medical imaging reports, laboratory test reports, discharge summaries, and outpatient records. In this system, we adopted the Health Level 7 (HL7) Clinical Document

  9. Electronic medical records in colorectal surgery.

    PubMed

    Turina, Matthias; Kiran, Ravi P

    2013-03-01

    Electronic medical records (EMRs) are being widely implemented today, either as stand-alone applications in smaller practices or as systems-based integrated network solutions in larger health care organizations. Advantages include rapid accessibility, worldwide availability, ease of storage, and secure transfer of protected health information (PHI). Computerized physician order entry (CPOE) and decision-support capabilities such as the triggering of an alarm when multiple medications with known interactions are ordered, as well as the seemingly endless possibilities for electronic integration and extraction of PHI for clinical and research purposes, have created opportunities and pitfalls alike. Risks include breaches of confidentiality with a need to implement tighter measures for electronic security. These measures contrast efforts required for the realization of common data formats that have national and even international compatibility. EMRs provide a common platform that could potentially allow for the integration and administration of clinical care, research, and quality metrics, thus promoting optimal outcomes for patients. Technical and medicolegal difficulties need to be overcome in the years to come so that the safe use of PHI can be ensured while still maintaining the benefits and convenience of modern EMR systems. PMID:24436643

  10. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 19 Customs Duties 3 2011-04-01 2011-04-01 false Special procedures: Medical records. 201.27... APPLICATION Safeguarding Individual Privacy Pursuant to 5 U.S.C. 552a § 201.27 Special procedures: Medical... maintained by the Commission which pertain to him or her, medical and psychological records merit...

  11. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 19 Customs Duties 3 2010-04-01 2010-04-01 false Special procedures: Medical records. 201.27... APPLICATION Safeguarding Individual Privacy Pursuant to 5 U.S.C. 552a § 201.27 Special procedures: Medical... maintained by the Commission which pertain to him or her, medical and psychological records merit...

  12. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 22 Foreign Relations 1 2012-04-01 2012-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for... records maintained by the Agency could have an adverse effect upon such individual, the...

  13. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 12 Banks and Banking 9 2012-01-01 2012-01-01 false Special procedure: Medical records. 1102.104... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health professional. When an individual requests access to records pertaining to the individual that include...

  14. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 7 2010-01-01 2010-01-01 false Special procedure: Medical records. 1102.104... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health professional. When an individual requests access to records pertaining to the individual that include...

  15. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 12 Banks and Banking 10 2014-01-01 2014-01-01 false Special procedure: Medical records. 1102.104... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health professional. When an individual requests access to records pertaining to the individual that include...

  16. The Importance of the Medical Record: A Critical Professional Responsibility.

    PubMed

    Ngo, Elizabeth; Patel, Nachiket; Chandrasekaran, Krishnaswamy; Tajik, A Jamil; Paterick, Timothy E

    2016-01-01

    Comprehensive, detailed documentation in the medical record is critical to patient care and to a physician when allegations of negligence arise. Physicians, therefore, would be prudent to have a clear understanding of this documentation. It is important to understand who is responsible for documentation, what is important to document, when to document, and how to document. Additionally, it should be understood who owns the medical record, the significance of the transition to the electronic medical record, problems and pitfalls when using the electronic medical record, and how the Health Information Technology for Economic and Clinical Health Act affects healthcare providers and health information technology. PMID:27249883

  17. Data discipline in electronic medical records

    PubMed Central

    Barber, David; Williamson, Tyler; Biro, Suzanne; Barber, Karen Hall; Martin, Danyal; Kinsella, Lorne; Morkem, Rachael

    2015-01-01

    Objective To evaluate the transformation in smoking status documentation after implementing a standardized intake tool as part of a primary care smoking cessation program. Design A before-and-after evaluation of smoking status documentation was conducted following implementation of a smoking assessment tool. To evaluate the effect of the intervention, the Canadian Primary Care Sentinel Surveillance Network was used to extract aggregate smoking data on the study cohort. Setting Academic primary care clinic in Kingston, Ont. Participants A total of 7312 primary care patients. Interventions As the first phase in a primary care smoking cessation program, a standardized intake tool was developed as part of a vital signs screening process. Main outcome measures Documented smoking status of patients before implementation of the intake tool and documented smoking status of patients in the 6 months after its implementation. Results Following the implementation of the standardized intake tool, there was a 55% (P < .001; 95% CI 0.53 to 0.56) increase in the proportion of patients with a completed smoking status; more than 1100 former smokers were identified and the documented smoking rate in this cohort increased from 4.4% to 16.2%. Conclusion This study shows that the implementation of an intake tool, integrated into existing clinical operational structures, is an effective way to standardize clinical documentation and promotes the optimization of electronic medical records. PMID:27035007

  18. Medical records department and balanced scorecard approach

    PubMed Central

    Ajami, Sima; Ebadsichani, Afsaneh; Tofighi, Shahram; Tavakoli, Nahid

    2013-01-01

    Context: The Medical Records Department (MRD) is an important source for evaluating and planning of healthcare services; therefore, hospital managers should improve their performance not only in the short-term but also in the long-term plans. The Balanced Scorecard (BSC) is a tool in the management system that enables organizations to correct operational functions and provides feedback around both the internal processes and the external outcomes, in order to improve strategic performance and outcomes continuously. Aims: The main goal of this study was to assess the MRD performance with BSC approach in a hospital. Materials and Methods: This research was an analytical cross-sectional study in which data was collected by questionnaires, forms and observation. The population was the staff of the MRD in a hospital in Najafabad, Isfahan, Iran. Statistical Analysis Used: To analyze data, first, objectives of the MRD, according to the mission and perspectives of the hospital, were redefined and, second, indicators were measured. Subsequently, findings from the performance were compared with the expected score. In order to achieve the final target, the programs, activities, and plans were reformed. Results: The MRD was successful in absorbing customer satisfaction. From a customer perspective, score in customer satisfaction of admission and statistics sections were 82% and 83%, respectively. Conclusions: The comprehensive nature of the strategy map makes the MRD especially useful as a consensus building and communication tool in the hospital. PMID:24083257

  19. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies...

  20. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies...

  1. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies...

  2. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies...

  3. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ...) Standard: Record retention and preservation. In accordance with 45 CFR § 164.530(j)(2), all patient records... Administration § 494.170 Condition: Medical records. The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies...

  4. Technology Acceptance of Electronic Medical Records by Nurses

    ERIC Educational Resources Information Center

    Stocker, Gary

    2010-01-01

    The purpose of this study was to evaluate the Technology Acceptance Model's (TAM) relevance of the intention of nurses to use electronic medical records in acute health care settings. The basic technology acceptance research of Davis (1989) was applied to the specific technology tool of electronic medical records (EMR) in a specific setting…

  5. 5 CFR 2504.6 - Special procedures for medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 5 Administrative Personnel 3 2014-01-01 2014-01-01 false Special procedures for medical records. 2504.6 Section 2504.6 Administrative Personnel OFFICE OF ADMINISTRATION, EXECUTIVE OFFICE OF THE PRESIDENT PRIVACY ACT REGULATIONS § 2504.6 Special procedures for medical records. (a) When the Privacy Act Officer receives a request from an...

  6. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 22 Foreign Relations 1 2011-04-01 2011-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for Administration or the Privacy Liaison Officer, determines that the release directly to the individual of...

  7. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... maintained by the Commission which pertain to him or her, medical and psychological records merit special treatment because of the possibility that disclosure will have an adverse physical or psychological effect... medical and/or psychological records which pertain to him or her, he or she shall, in his or her...

  8. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... maintained by the Commission which pertain to him or her, medical and psychological records merit special treatment because of the possibility that disclosure will have an adverse physical or psychological effect... medical and/or psychological records which pertain to him or her, he or she shall, in his or her...

  9. 19 CFR 201.27 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... maintained by the Commission which pertain to him or her, medical and psychological records merit special treatment because of the possibility that disclosure will have an adverse physical or psychological effect... medical and/or psychological records which pertain to him or her, he or she shall, in his or her...

  10. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 22 Foreign Relations 1 2014-04-01 2014-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for Administration or the Privacy Liaison Officer, determines that the release directly to the individual of...

  11. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 22 Foreign Relations 1 2010-04-01 2010-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for Administration or the Privacy Liaison Officer, determines that the release directly to the individual of...

  12. 22 CFR 215.6 - Special procedures: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 22 Foreign Relations 1 2013-04-01 2013-04-01 false Special procedures: Medical records. 215.6... PRIVACY ACT OF 1974 § 215.6 Special procedures: Medical records. If the Assistant Director for Administration or the Privacy Liaison Officer, determines that the release directly to the individual of...

  13. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... doctor or other person to act as his agent as described in § 701.310(a). Records containing medical or... request. (b) If the individual has not named a medical doctor as agent, the Council may determine, after consultation with a medical doctor, that disclosure of the information would have an adverse effect on...

  14. [Duodenal duplication].

    PubMed

    Ilari, J; Martorell, R; Morales, M; Capdevila, M; Mairal, J A; Teixidó, M; Casadellá, A

    1998-01-01

    Cystic duplication of the duodenum is a rare anomaly of the gastrointestinal tract. This is a report of a newborn with a cystic duplication of duodenum diagnosed prenatally. It's relevant the few clinical symptoms of a such big mass. The surgical procedure was excision of the cyst, with a good post operative curse. PMID:9662869

  15. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... Section 17.905 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Health Care Benefits for Certain Children of Vietnam Veterans-Spina Bifida and Covered Birth Defects § 17.905 Medical... Reimbursement for Emergency Services for Nonservice-Connected Conditions in Non-VA Facilities Source: 66...

  16. Blanks on medical records may give payers denial ammo.

    PubMed

    Gardner, E

    1991-10-21

    Incomplete and inaccurate patient records have always left hospitals vulnerable to losing malpractice suits. But increasingly, good records mean hospitals are more likely to collect on bills that are scrutinized by utilization review firms, Medicare peer review organizations and other such bill examiners. That places a higher premium than ever on paying meticulous attention to a patient's medical record. PMID:10114223

  17. The use of electronic medication reconciliation to establish the predictors of validity of computerized medication records.

    PubMed

    Turchin, Alexander; Gandhi, Tejal K; Coley, Christopher M; Shubina, Maria; Broverman, Carol

    2007-01-01

    Medication records in clinical information systems (CIS) are frequently inaccurate, leading to potentially incorrect clinical decisions and preventing valid decision support interventions. It is not known what characteristics of electronic medication records are predictive of their validity. We studied a dataset of 136,351 electronic medication records of patients admitted to two academic hospitals that were individually validated by admitting providers using novel medication reconciliation software. We analyzed the relationship between characteristics of individual medication records and the probability of record validation using a multivariable linear regression model. Electronic medication records were less likely to be validated if more time had passed since their last update (14.6% for every 6 months), if they represented an antiinfective (61.6%) or a prn (50.9%) medication, or if they were in an outpatient CIS rather than on an inpatient discharge medication list (18.1%); p<0.0001 for all. Several characteristics of electronic medication records are strongly associated with their validity. These findings could be incorporated in the design of CIS software to alert providers to medication records less likely to be accurate. PMID:17911870

  18. Interior, middle wing, medical records storage. Notice roof trusses. ...

    Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

    Interior, middle wing, medical records storage. Notice roof trusses. - Fitzsimons General Hospital, Nurses' Mess & Kitchen, Nurses' Recreation, West McAfee Avenue, North of Building 507, Aurora, Adams County, CO

  19. [Accessing medical records for research purposes].

    PubMed

    Alcalde Bezhold, Guillermo; Alfonso Farnós, Iciar

    2013-01-01

    The Organic Law 15/1999 of 13 December on the Protection of Personal Data and the Law 41/2002 of 14 November regulating patient autonomy and rights and obligations of information and clinical documentation are the basic rules which govern the medical history in Spain. However, the lack of development of these laws regarding data protection in clinical research, particularly in terms of access to the medical history, repeatedly causes doubts about its construction by the Research Ethics Committees. Therefore, the aim of this paper is to analyze the rules which govern the access to the medical history for research purposes, with particular emphasis on the common problems that arise in the Committees for the ethical evaluation of these projects and finally setting a series of recommendations. The use for research purpose of genetic personal data contained in the medical history is also addressed in this paper. In this sense, a key contribution of the Law on Biomedical Research is relating to the specific regulation of the genetic personal data, both with respect to their production and access to the data as a support and regarding to its use for research purpose. PMID:24868961

  20. The New World of Interaction Recording for Medical Practices.

    PubMed

    Levy, Michael

    2016-01-01

    Today's medical practice staff communicates remotely with patients, pharmacies, and other medical providers in new ways that go far beyond telephone calls. Patient care and communication are now being provided via telecommunications technologies, including chat/IM, screen, Skype, and other video applications. This new paradigm in patient care, known as "telehealth" or "telemedicine," could put medical practices at risk for noncompliance with strict HIPAA and other regulations. Interaction recording encompasses these new means of communication and can help medical practice staff achieve compliance and reduce financial and liability risks while improving operations and patient care. This article explores what medical practices need to know about interaction recording, what to look for in an interaction recording solution, and how to best utilize that solution to meet compliance, manage liability, and improve patient care. PMID:27039643

  1. Duplicated laboratory tests: evaluation of a computerized alert intervention abstract.

    PubMed

    Bridges, Sharon A; Papa, Linda; Norris, Anne E; Chase, Susan K

    2014-01-01

    Redundant testing contributes to reductions in healthcare system efficiency. The purpose of this study was to: (1) determine if the use of a computerized alert would reduce the number and cost of duplicated Acute Hepatitis Profile (AHP) laboratory tests and (2) assess what patient, test, and system factors were associated with duplication. This study used a quasi-experimental pre- and post-test design to determine the proportion of duplication of the AHP test before and after implementation of a computerized alert intervention. The AHP test was duplicated if the test was requested again within 15 days of the initial test being performed and the result present in the medical record. The intervention consisted of a computerized alert (pop-up window) that indicated to the clinician that the test had recently been ordered. A total of 674 AHP tests were performed in the pre-intervention period and 692 in the postintervention group. In the pre-intervention period, 53 (7.9%) were duplicated and in postintervention, 18 (2.6%) were duplicated (p<.001). The implementation of the alert was shown to significantly reduce associated costs of duplicated AHP tests (p≤.001). Implementation of computerized alerts may be useful in reducing duplicate laboratory tests and improving healthcare system efficiency. PMID:22963261

  2. Medical records and the Middle East: a partnership in development.

    PubMed

    Hostetler, D

    1986-01-01

    Mention the Middle East and many people think of giant oil exports. However, medical record professionals have been importing their expertise to the region for more than 20 years, and in the process, making a valuable contribution to modernizing the health care systems in these countries. This article describes the experiences of some of these medical record pioneers and offers insights into changes in the region which will affect future expatriates. PMID:10275062

  3. An Unsuccessful Experience with Computerized Medical Records in an Academic Medical Center.

    ERIC Educational Resources Information Center

    Dambro, Mark R.; And Others

    1988-01-01

    Experience with the Computer Stored Ambulatory Record (COSTAR), a computerized medical records system, installed at a large primary care clinic at a university medical center is reported. Use of the system was terminated because clinic revenues could not cover operating costs. (Author/MLW)

  4. Medical education in the electronic medical record (EMR) era: benefits, challenges, and future directions.

    PubMed

    Tierney, Michael J; Pageler, Natalie M; Kahana, Madelyn; Pantaleoni, Julie L; Longhurst, Christopher A

    2013-06-01

    In the last decade, electronic medical record (EMR) use in academic medical centers has increased. Although many have lauded the clinical and operational benefits of EMRs, few have considered the effect these systems have on medical education. The authors review what has been documented about the effect of EMR use on medical learners through the lens of the Accreditation Council for Graduate Medical Education's six core competencies for medical education. They examine acknowledged benefits and educational risks to use of EMRs, consider factors that promote their successful use when implemented in academic environments, and identify areas of future research and optimization of EMRs' role in medical education. PMID:23619078

  5. Predicting Medical Specialty Choice: A Model Based on Students' Records.

    ERIC Educational Resources Information Center

    Fadem, Barbara H.; And Others

    1984-01-01

    A discriminant analysis of objective and subjective measures from the records of students who graduated from the University of Medicine and Dentistry of New Jersey-New Jersey Medical School over a six-year period was used to generate a model for the prediction of medical specialty choice. (Author/MLW)

  6. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Medical magnetic tape recorder. 870.2800 Section 870.2800 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Monitoring Devices § 870.2800...

  7. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Medical magnetic tape recorder. 870.2800 Section 870.2800 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Monitoring Devices § 870.2800...

  8. 21 CFR 870.2800 - Medical magnetic tape recorder.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Medical magnetic tape recorder. 870.2800 Section 870.2800 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Monitoring Devices § 870.2800...

  9. Electronic Medical Records and Their Impact on Resident and Medical Student Education

    ERIC Educational Resources Information Center

    Keenan, Craig R.; Nguyen, Hien H.; Srinivasan, Malathi

    2006-01-01

    Objective: Electronic medical records (EMRs) are becoming prevalent and integral tools for residents and medical students. EMRs can integrate point-of-service information delivery within the context of patient care. Though it may be an educational tool, little is known about how EMR technology is currently used for medical learners. Method: The…

  10. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health... or a mental health professional indicating that, in his or her opinion, disclosure of the requested...) Designation of physician or mental health professional to receive records. If the ASC believes, in good...

  11. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... Subcommittee § 1102.104 Special procedure: Medical records. (a) Statement of physician or mental health... or a mental health professional indicating that, in his or her opinion, disclosure of the requested...) Designation of physician or mental health professional to receive records. If the ASC believes, in good...

  12. 20 CFR 401.55 - Access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Access to medical records. 401.55 Section 401.55 Employees' Benefits SOCIAL SECURITY ADMINISTRATION PRIVACY AND DISCLOSURE OF OFFICIAL RECORDS AND... physician, other health professional, or other responsible individual who will be willing to review...

  13. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 44 Emergency Management and Assistance 1 2014-10-01 2014-10-01 false Special requirements for medical records. 6.31 Section 6.31 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY GENERAL IMPLEMENTATION OF THE PRIVACY ACT OF 1974 Individual Access to Records § 6.31 Special requirements...

  14. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... Program’ (see 32 CFR part 310). ... 32 National Defense 2 2011-07-01 2011-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records...

  15. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... Program’ (see 32 CFR part 310). ... 32 National Defense 2 2013-07-01 2013-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records...

  16. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... Program’ (see 32 CFR part 310). ... 32 National Defense 2 2014-07-01 2014-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records...

  17. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... Program’ (see 32 CFR part 310). ... 32 National Defense 2 2012-07-01 2012-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records...

  18. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... Program’ (see 32 CFR part 310). ... 32 National Defense 2 2010-07-01 2010-07-01 false Access to medical and psychological records. 324... to medical and psychological records. Individual access to medical and psychological records...

  19. Medical Record Clerk Training Program, Course of Study; Student Manual: For Medical Record Personnel in Small Rural Hospitals in Colorado.

    ERIC Educational Resources Information Center

    Community Health Service (DHEW/PHS), Arlington, VA. Div. of Health Resources.

    The manual provides major topics, objectives, activities and, procedures, references and materials, and assignments for the training program. The topics covered are hospital organization and community role, organization and management of a medical records department, international classification of diseases and operations, medical terminology,…

  20. 10 CFR 9.35 - Duplication fees.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 false Duplication fees. 9.35 Section 9.35 Energy NUCLEAR REGULATORY COMMISSION PUBLIC RECORDS Freedom of Information Act Regulations § 9.35 Duplication fees. (a)(1) The charges by the duplicating service contractor for the duplication of records made available under § 9.21 at the NRC Public Document Room...

  1. Building Structured Personal Health Records from Photographs of Printed Medical Records

    PubMed Central

    Li, Xiang; Hu, Gang; Teng, Xiaofei; Xie, Guotong

    2015-01-01

    Personal health records (PHRs) provide patient-centric healthcare by making health records accessible to patients. In China, it is very difficult for individuals to access electronic health records. Instead, individuals can easily obtain the printed copies of their own medical records, such as prescriptions and lab test reports, from hospitals. In this paper, we propose a practical approach to extract structured data from printed medical records photographed by mobile phones. An optical character recognition (OCR) pipeline is performed to recognize text in a document photo, which addresses the problems of low image quality and content complexity by image pre-processing and multiple OCR engine synthesis. A series of annotation algorithms that support flexible layouts are then used to identify the document type, entities of interest, and entity correlations, from which a structured PHR document is built. The proposed approach was applied to real world medical records to demonstrate the effectiveness and applicability. PMID:26958219

  2. Concordance between medical records and interview data in correctional facilities

    PubMed Central

    2014-01-01

    Background Self- administered questionnaires or interviews and medical records are often used as sources of research data; thus it is essential to evaluate their concordance and reliability. The aim of this paper was to assess the concordance between medical and behavioral data obtained from medical records and interview questionnaires in two correctional facilities. Methods Medical record and interview data were compared for 679 inmates from one male and one female maximum security prison between April 2010 and February 2013. Gender non-stratified and gender-stratified analyses were conducted in SPSS to calculate the prevalence and kappa coefficient scores (κ) for medical (e.g., HIV, diabetes, hypertension) and behavioral (e.g., smoking, drug use, tattoos) conditions. Sensitivity/specificity between medical records and interview were calculated in the gender non-stratified data. Results In the gender non-stratified analysis, κ score for HIV, hepatitis C, diabetes, asthma, and history of tattoos had strong or good concordance (0.66-0.89). Hypertension, renal/kidney disease, cigarette smoking, antibiotic use in the last 6 months, and cocaine use ever were moderately correlated (0.49-0.57). Both history of any illicit drug use ever (0.36) and marijuana use ever (0.23) had poor concordance. Females had higher κ scores and prevalence rates than males overall. Medical conditions were reported more frequently in medical records and behavioral conditions had higher prevalence in interviews. Sensitivity for medical conditions in the combined facility data ranged from 50.0% to 86.0% and 48.2% to 85.3% for behavioral conditions whereas specificity ranged from 95.9% to 99.5% for medical conditions and 75.9% to 92.8% for behavioral conditions. Conclusion Levels of agreement between medical records and self-reports varied by type of factor. Medical conditions were more frequently reported by chart review and behavioral factors more frequently by self-report. Data source

  3. CRFs based de-identification of medical records

    PubMed Central

    He, Bin; Guan, Yi; Cheng, Jianyi; Cen, Keting; Hua, Wenlan

    2016-01-01

    De-identification is a shared task of the 2014 i2b2/UTHealth challenge. The purpose of this task is to remove protected health information (PHI) from medical records. In this paper, we propose a novel de-identifier, WI-deId, based on conditional random fields (CRFs). A preprocessing module, which tokenizes the medical records using regular expressions and an off-the-shelf tokenizer, is introduced, and three groups of features are extracted to train the de-identifier model. The experiment shows that our system is effective in the de-identification of medical records, achieving a micro-F1 of 0.9232 at the i2b2 strict entity evaluation level. PMID:26315662

  4. Medical records to be placed online by some HMOs.

    PubMed

    Fine, Allan

    2004-01-01

    In recent years, health care policy experts have been urging medical institutions to convert their paper records to electronic form as an important step to avoid medication errors and other mistakes caused by incomplete patient information. Electronic systems also facilitate evaluation of individual physicians and the effectiveness of new treatments. Given the technology's enormous cost, coupled with the difficulty of persuading busy physicians to change the way they practice, as well as the privacy concerns, adoption has been slowed. PMID:15685816

  5. Real and imagined barriers to an electronic medical record.

    PubMed

    Rind, D M; Safran, C

    1993-01-01

    We developed an electronic medical record for ambulatory patients as part of the integrated clinical information system at Beth Israel Hospital. During the four years since it was installed, clinicians have entered 76,060 patient problems, 137,713 medications, and 33,938 notes. Residents, who had to type notes in themselves, entered 49.5% of their notes into OMR. Several factors that we had predicted would be barriers to an electronic medical record, such as clinician reluctance to type or perform data entry, have not proved to be significant problems. Other anticipated barriers, such as difficulties with dual charting on paper during transition to an electronic medical record, have been realized. The major unexpected barrier that has been encountered is increased clinician concern about the privacy and security of full text notes relative to other data elements in the clinical information system. We have attempted to modify the electronic medical record so as to overcome some of these barriers. PMID:8130574

  6. Medical and peer review records in malpractice litigation.

    PubMed

    Florin, D; Murphy, J G

    1992-01-01

    Medical records and peer review documents are important items in assessing claims brought against physicians for malpractice. In the United States, the adequacy of these documents and the extent to which their production can be mandatory is a complex subject governed by the statutory and/or common law of the individual states. Spoliation of medical records is not frequently encountered and will probably remain an isolated phenomenon. There is, however, constant development in the law regarding the discovery of documents compiled by health care providers and the extent to which these can be considered to constitute privileged information. PMID:23511097

  7. Information integrity and privacy for computerized medical patient records

    SciTech Connect

    Gallegos, J.; Hamilton, V.; Gaylor, T.; McCurley, K.; Meeks, T.

    1996-09-01

    Sandia National Laboratories and Oceania, Inc. entered into a Cooperative Research and Development Agreement (CRADA) in November 1993 to provide ``Information Integrity and Privacy for Computerized Medical Patient Records`` (CRADA No. SC93/01183). The main objective of the project was to develop information protection methods that are appropriate for databases of patient records in health information systems. This document describes the findings and alternative solutions that resulted from this CRADA.

  8. 28 CFR 79.5 - Requirements for medical documentation, contemporaneous records, and other records or documents.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Requirements for medical documentation, contemporaneous records, and other records or documents. 79.5 Section 79.5 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CLAIMS UNDER THE RADIATION EXPOSURE COMPENSATION ACT General § 79.5 Requirements...

  9. 28 CFR 79.5 - Requirements for medical documentation, contemporaneous records, and other records or documents.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Requirements for medical documentation, contemporaneous records, and other records or documents. 79.5 Section 79.5 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CLAIMS UNDER THE RADIATION EXPOSURE COMPENSATION ACT General § 79.5 Requirements...

  10. 28 CFR 79.5 - Requirements for medical documentation, contemporaneous records, and other records or documents.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Requirements for medical documentation, contemporaneous records, and other records or documents. 79.5 Section 79.5 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CLAIMS UNDER THE RADIATION EXPOSURE COMPENSATION ACT General § 79.5 Requirements...

  11. 28 CFR 79.5 - Requirements for medical documentation, contemporaneous records, and other records or documents.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 28 Judicial Administration 2 2011-07-01 2011-07-01 false Requirements for medical documentation, contemporaneous records, and other records or documents. 79.5 Section 79.5 Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) CLAIMS UNDER THE RADIATION EXPOSURE COMPENSATION ACT General § 79.5 Requirements...

  12. Are In-Bed Electronic Weights Recorded in the Medical Record Accurate?

    PubMed

    Gerl, Heather; Miko, Alexandra; Nelson, Mandy; Godaire, Lori

    2016-01-01

    This study found large discrepancies between in-bed weights recorded in the medical record and carefully obtained standing weights with a calibrated, electronic bedside scale. This discrepancy appears to be related to inadequate bed calibration before patient admission and having excessive linen, clothing, and/or equipment on the bed during weighing by caregivers. PMID:27522846

  13. 41 CFR 105-64.208 - What special conditions apply to release of medical records?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... apply to release of medical records? 105-64.208 Section 105-64.208 Public Contracts and Property....208 What special conditions apply to release of medical records? Medical records containing... writing by you, or by your guardian or conservator. Medical records in an Official Personnel Folder...

  14. 41 CFR 105-64.208 - What special conditions apply to release of medical records?

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... apply to release of medical records? 105-64.208 Section 105-64.208 Public Contracts and Property....208 What special conditions apply to release of medical records? Medical records containing... writing by you, or by your guardian or conservator. Medical records in an Official Personnel Folder...

  15. 41 CFR 105-64.208 - What special conditions apply to release of medical records?

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... apply to release of medical records? 105-64.208 Section 105-64.208 Public Contracts and Property....208 What special conditions apply to release of medical records? Medical records containing... writing by you, or by your guardian or conservator. Medical records in an Official Personnel Folder...

  16. 41 CFR 105-64.208 - What special conditions apply to release of medical records?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... apply to release of medical records? 105-64.208 Section 105-64.208 Public Contracts and Property....208 What special conditions apply to release of medical records? Medical records containing... writing by you, or by your guardian or conservator. Medical records in an Official Personnel Folder...

  17. 41 CFR 105-64.208 - What special conditions apply to release of medical records?

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... apply to release of medical records? 105-64.208 Section 105-64.208 Public Contracts and Property....208 What special conditions apply to release of medical records? Medical records containing... writing by you, or by your guardian or conservator. Medical records in an Official Personnel Folder...

  18. 36 CFR 1202.42 - How are requests for access to medical records handled?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... to medical records handled? 1202.42 Section 1202.42 Parks, Forests, and Public Property NATIONAL... Individual Access to Records § 1202.42 How are requests for access to medical records handled? When NARA receives a request for access to medical records, if NARA believes that disclosure of medical...

  19. 36 CFR 1202.42 - How are requests for access to medical records handled?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... medical records handled? 1202.42 Section 1202.42 Parks, Forests, and Public Property NATIONAL ARCHIVES AND... Records § 1202.42 How are requests for access to medical records handled? When NARA receives a request for access to medical records, if NARA believes that disclosure of medical and/or psychological...

  20. 36 CFR 1202.42 - How are requests for access to medical records handled?

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... to medical records handled? 1202.42 Section 1202.42 Parks, Forests, and Public Property NATIONAL... Individual Access to Records § 1202.42 How are requests for access to medical records handled? When NARA receives a request for access to medical records, if NARA believes that disclosure of medical...

  1. 20 CFR 10.800 - What kind of medical records must providers keep?

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false What kind of medical records must providers...' COMPENSATION ACT, AS AMENDED Information for Medical Providers Medical Records and Bills § 10.800 What kind of medical records must providers keep? Agency medical officers, private physicians and hospitals...

  2. 20 CFR 30.700 - What kinds of medical records must providers keep?

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false What kinds of medical records must providers... for Medical Providers Medical Records and Bills § 30.700 What kinds of medical records must providers keep? Federal Government medical officers, private physicians and hospitals are required to...

  3. 20 CFR 30.700 - What kinds of medical records must providers keep?

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 20 Employees' Benefits 1 2011-04-01 2011-04-01 false What kinds of medical records must providers... for Medical Providers Medical Records and Bills § 30.700 What kinds of medical records must providers keep? Federal Government medical officers, private physicians and hospitals are required to...

  4. 20 CFR 10.800 - What kind of medical records must providers keep?

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 20 Employees' Benefits 1 2011-04-01 2011-04-01 false What kind of medical records must providers...' COMPENSATION ACT, AS AMENDED Information for Medical Providers Medical Records and Bills § 10.800 What kind of medical records must providers keep? Agency medical officers, private physicians and hospitals...

  5. 20 CFR 30.700 - What kinds of medical records must providers keep?

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 20 Employees' Benefits 1 2013-04-01 2012-04-01 true What kinds of medical records must providers... for Medical Providers Medical Records and Bills § 30.700 What kinds of medical records must providers keep? Federal Government medical officers, private physicians and hospitals are required to...

  6. 20 CFR 30.700 - What kinds of medical records must providers keep?

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 20 Employees' Benefits 1 2014-04-01 2012-04-01 true What kinds of medical records must providers... for Medical Providers Medical Records and Bills § 30.700 What kinds of medical records must providers keep? Federal Government medical officers, private physicians and hospitals are required to...

  7. 20 CFR 30.700 - What kinds of medical records must providers keep?

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 20 Employees' Benefits 1 2012-04-01 2012-04-01 false What kinds of medical records must providers... for Medical Providers Medical Records and Bills § 30.700 What kinds of medical records must providers keep? Federal Government medical officers, private physicians and hospitals are required to...

  8. Physician Sensemaking and Readiness for Electronic Medical Records

    ERIC Educational Resources Information Center

    Riesenmy, Kelly Rouse

    2010-01-01

    Purpose: The purpose of this paper is to explore physician sensemaking and readiness to implement electronic medical records (EMR) as a first step to finding strategies that enhance EMR adoption behaviors. Design/methodology/approach: The case study approach provides a detailed analysis of individuals within an organizational unit. Using a…

  9. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020; and....S.C. 793, and its implementing rules, including confidentiality provisions in 41 CFR 60-741.23...

  10. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020; and....S.C. 793, and its implementing rules, including confidentiality provisions in 41 CFR 60-741.23...

  11. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020; and....S.C. 793, and its implementing rules, including confidentiality provisions in 41 CFR 60-741.23...

  12. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... accordance with the Privacy Act, 5 U.S.C. 552a, and DOE implementing regulations in 10 CFR part 1008; the Department of Labor's regulations on access to individual exposure and medical records, 29 CFR 1910.1020; and....S.C. 793, and its implementing rules, including confidentiality provisions in 41 CFR 60-741.23...

  13. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 2 2012-07-01 2012-07-01 false Special procedures: Medical records. 319.7 Section 319.7 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures:...

  14. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 2 2014-07-01 2014-07-01 false Special procedures: Medical records. 319.7 Section 319.7 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures:...

  15. 32 CFR 319.7 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Special procedures: Medical records. 319.7 Section 319.7 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) PRIVACY PROGRAM DEFENSE INTELLIGENCE AGENCY PRIVACY PROGRAM § 319.7 Special procedures:...

  16. Evaluation of a Lecture Recording System in a Medical Curriculum

    ERIC Educational Resources Information Center

    Bacro, Thierry R. H.; Gebregziabher, Mulugeta; Fitzharris, Timothy P.

    2010-01-01

    Recently, the Medical University of South Carolina adopted a lecture recording system (LRS). A retrospective study of LRS was implemented to document the students' perceptions, pattern of usage, and impact on the students' grades in three basic sciences courses (Cell Biology/Histology, Physiology, and Neurosciences). The number of accesses and…

  17. A Codasyl-Type Schema for Natural Language Medical Records

    PubMed Central

    Sager, N.; Tick, L.; Story, G.; Hirschman, L.

    1980-01-01

    This paper describes a CODASYL (network) database schema for information derived from narrative clinical reports. The goal of this work is to create an automated process that accepts natural language documents as input and maps this information into a database of a type managed by existing database management systems. The schema described here represents the medical events and facts identified through the natural language processing. This processing decomposes each narrative into a set of elementary assertions, represented as MEDFACT records in the database. Each assertion in turn consists of a subject and a predicate classed according to a limited number of medical event types, e.g., signs/symptoms, laboratory tests, etc. The subject and predicate are represented by EVENT records which are owned by the MEDFACT record associated with the assertion. The CODASYL-type network structure was found to be suitable for expressing most of the relations needed to represent the natural language information. However, special mechanisms were developed for storing the time relations between EVENT records and for recording connections (such as causality) between certain MEDFACT records. This schema has been implemented using the UNIVAC DMS-1100 DBMS.

  18. How Patients Can Improve the Accuracy of their Medical Records

    PubMed Central

    Dullabh, Prashila M.; Sondheimer, Norman K.; Katsh, Ethan; Evans, Michael A.

    2014-01-01

    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

  19. Extracting Cancer Quality Indicators from Electronic Medical Records: Evaluation of an Ontology-Based Virtual Medical Record Approach

    PubMed Central

    Lee, Wei-Nchih; Tu, Samson W.; Das, Amar K.

    2009-01-01

    Measuring quality in clinical care is a time-consuming manual task. The vast amounts of clinical data collected through electronic medical records (EMRs) create an opportunity to develop tools that automatically assess quality indicators; however, the diversity of EMR implementations limits the ability to implement general, reusable methods. We evaluate an ontology-based virtual medical record (VMR) approach as a standardized, sharable methodology for defining data abstractions needed for quality of care assessment. Using a set of cancer quality indicators, we conducted a requirements analysis for modeling these abstractions with an OWL-based VMR. We found that the VMR approach needs to be extended to support population-based aggregations of clinical events, models of intended versus completed actions, and models of workflow and delivery systems. Incorporating the patient perspective on quality also requires additional extension of the VMR. We are using these results to create a virtual quality record based on EMR data. PMID:20351878

  20. Medical record: systematic centralization versus secure on demand aggregation

    PubMed Central

    2011-01-01

    Background As patients often see the data of their medical histories scattered among various medical records hosted in several health-care establishments, the purpose of our multidisciplinary study was to define a pragmatic and secure on-demand based system able to gather this information, with no risk of breaching confidentiality, and to relay it to a medical professional who asked for the information via a specific search engine. Methods Scattered data are often heterogeneous, which makes the task of gathering information very hard. Two methods can be compared: trying to solve the problem by standardizing and centralizing all the information about every patient in a single Medical Record system or trying to use the data "as is" and find a way to obtain the most complete and the most accurate information. Given the failure of the first approach, due to the lack of standardization or privacy and security problems, for example, we propose an alternative that relies on the current state of affairs: an on-demand system, using a specific search engine that is able to retrieve information from the different medical records of a single patient. Results We describe the function of Medical Record Search Engines (MRSE), which are able to retrieve all the available information regarding a patient who has been hospitalized in different hospitals and to provide this information to health professionals upon request. MRSEs use pseudonymized patient identities and thus never have access to the patient's identity. However, though the system would be easy to implement as it by-passes many of the difficulties associated with a centralized architecture, the health professional would have to validate the information, i.e. read all of the information and create his own synthesis and possibly reject extra data, which could be a drawback. We thus propose various feasible improvements, based on the implementation of several tools in our on-demand based system. Conclusions A system that

  1. Integrating all medical records to an enterprise viewer.

    PubMed

    Li, Haomin; Duan, Huilong; Lu, Xudong; Zhao, Chenhui; An, Jiye

    2005-01-01

    The idea behind hospital information systems is to make all of a patient's medical reports, lab results, and images electronically available to clinicians, instantaneously, wherever they are. But the higgledy-piggledy evolution of most hospital computer systems makes it hard to integrate all these clinical records. Although several integration standards had been proposed to meet this challenger, none of them is fit to Chinese hospitals. In this paper, we introduce our work of implementing a three-tiered architecture enterprise viewer in Huzhou Central Hospital to integration all existing medical information systems using limited resource. PMID:17282239

  2. Data-Driven Information Extraction from Chinese Electronic Medical Records

    PubMed Central

    Zhao, Tianwan; Ge, Chen; Gao, Weiguo; Wei, Jia; Zhu, Kenny Q.

    2015-01-01

    Objective This study aims to propose a data-driven framework that takes unstructured free text narratives in Chinese Electronic Medical Records (EMRs) as input and converts them into structured time-event-description triples, where the description is either an elaboration or an outcome of the medical event. Materials and Methods Our framework uses a hybrid approach. It consists of constructing cross-domain core medical lexica, an unsupervised, iterative algorithm to accrue more accurate terms into the lexica, rules to address Chinese writing conventions and temporal descriptors, and a Support Vector Machine (SVM) algorithm that innovatively utilizes Normalized Google Distance (NGD) to estimate the correlation between medical events and their descriptions. Results The effectiveness of the framework was demonstrated with a dataset of 24,817 de-identified Chinese EMRs. The cross-domain medical lexica were capable of recognizing terms with an F1-score of 0.896. 98.5% of recorded medical events were linked to temporal descriptors. The NGD SVM description-event matching achieved an F1-score of 0.874. The end-to-end time-event-description extraction of our framework achieved an F1-score of 0.846. Discussion In terms of named entity recognition, the proposed framework outperforms state-of-the-art supervised learning algorithms (F1-score: 0.896 vs. 0.886). In event-description association, the NGD SVM is superior to SVM using only local context and semantic features (F1-score: 0.874 vs. 0.838). Conclusions The framework is data-driven, weakly supervised, and robust against the variations and noises that tend to occur in a large corpus. It addresses Chinese medical writing conventions and variations in writing styles through patterns used for discovering new terms and rules for updating the lexica. PMID:26295801

  3. National electronic medical records integration on cloud computing system.

    PubMed

    Mirza, Hebah; El-Masri, Samir

    2013-01-01

    Few Healthcare providers have an advanced level of Electronic Medical Record (EMR) adoption. Others have a low level and most have no EMR at all. Cloud computing technology is a new emerging technology that has been used in other industry and showed a great success. Despite the great features of Cloud computing, they haven't been utilized fairly yet in healthcare industry. This study presents an innovative Healthcare Cloud Computing system for Integrating Electronic Health Record (EHR). The proposed Cloud system applies the Cloud Computing technology on EHR system, to present a comprehensive EHR integrated environment. PMID:23920993

  4. The effect of the electronic medical record on nurses' work.

    PubMed

    Robles, Jane

    2009-01-01

    The electronic medical record (EMR) is a workplace reality for most nurses. Its advantages include a single consolidated record for each person; capacity for data interfaces and alerts; improved interdisciplinary communication; and evidence-based decision support. EMRs can add to work complexity, by forcing better documentation of previously unrecorded data and/or because of poor design. Well-designed and well-implemented computerized provider order entry (CPOE) systems can streamline nurses' work. Generational differences in acceptance of and facility with EMRs can be addressed through open, healthy communication. PMID:19343848

  5. Physicians’ Attitudes regarding Patient Access to Electronic Medical Records

    PubMed Central

    Dorr, David A.; Rowan, Belle; Weed, Matt; James, Brent; Clayton, Paul

    2003-01-01

    Prior to the implementation of Electronic Medical Record (EMR) web access for patients at a large integrated delivery systems, we surveyed physicians’ attitudes. Our web based questionnaire revealed largely positive attitudes about access. The exceptions included abnormal reports, progress notes, and e-care. A factor analysis identified the group of physicians who didn’t view patients as partners felt most negative about the process. PMID:14728337

  6. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Disclosing the medical records of minors. 806b... ADMINISTRATION PRIVACY ACT PROGRAM Disclosing Records to Third Parties § 806b.48 Disclosing the medical records of minors. Air Force personnel may disclose the medical records of minors to their parents or...

  7. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 6 2013-07-01 2013-07-01 false Disclosing the medical records of minors. 806b... ADMINISTRATION PRIVACY ACT PROGRAM Disclosing Records to Third Parties § 806b.48 Disclosing the medical records of minors. Air Force personnel may disclose the medical records of minors to their parents or...

  8. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 6 2011-07-01 2011-07-01 false Disclosing the medical records of minors. 806b... ADMINISTRATION PRIVACY ACT PROGRAM Disclosing Records to Third Parties § 806b.48 Disclosing the medical records of minors. Air Force personnel may disclose the medical records of minors to their parents or...

  9. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 6 2014-07-01 2014-07-01 false Disclosing the medical records of minors. 806b... ADMINISTRATION PRIVACY ACT PROGRAM Disclosing Records to Third Parties § 806b.48 Disclosing the medical records of minors. Air Force personnel may disclose the medical records of minors to their parents or...

  10. 32 CFR 806b.48 - Disclosing the medical records of minors.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 6 2012-07-01 2012-07-01 false Disclosing the medical records of minors. 806b... ADMINISTRATION PRIVACY ACT PROGRAM Disclosing Records to Third Parties § 806b.48 Disclosing the medical records of minors. Air Force personnel may disclose the medical records of minors to their parents or...

  11. The Emerging Role of Electronic Medical Records in Pharmacogenomics

    PubMed Central

    Wilke, RA; Xu, H; Denny, JC; Roden, DM; Krauss, RM; McCarty, CA; Davis, RL; Skaar, T; Lamba, J; Savova, G

    2011-01-01

    Healthcare information technology and genotyping technology are both advancing rapidly, creating new opportunities for medical and scientific discovery. The convergence of these two technologies is now facilitating genetic association studies of unprecedented size within the context of routine clinical care. As a result, the medical community will soon be presented with a number of novel opportunities to bring functional genomics to the bedside in the area of pharmacotherapy. By linking biological material to comprehensive medical records, large multi-institutional biobanks are now poised to advance the field of pharmacogenomics through three distinct mechanisms: (1) retrospective assessment of previously known findings in a clinical practice-based setting, (2) discovery of new associations in huge observational cohorts, and (3) prospective application in a setting capable of providing real-time decision support. The current review explores each of these translational mechanisms within an historical framework. PMID:21248726

  12. [Medical and pharmaceutical tales recorded in "Genroku- Sekenbanashi-Fubunshu"].

    PubMed

    Hamada, T

    1996-12-01

    "Genroku-Sekenbanashi-Fubunshu" consists of eleven volumes and was written from 1694 to 1703, in the Edo Period. The original book was kept at the Faculty of Literature, Tokyo University. In 1994, this book was first published as one of the Iwanami-Bunko Series. I studied the tales recorded in this book and found that twenty-seven of them were concerned with medical and pharmaceutial sciences. In these medical and pharmaceutical tales, there were several kinds, relating to such matters as spells to cure or prevent illness, curious sicknesses, episodes regarding the origin of remedies, medicinal plants and crude drugs, medical books, doctors and surgeons, persons who lived long, and so forth. It was difficult to explain about the spells which were thought effective to cure illness, but I could gain an understanding that Japanese people lived such lives in the old days. PMID:11619293

  13. Recording and podcasting of lectures for students of medical school.

    PubMed

    Brunet, Pierre; Cuggia, Marc; Le Beux, Pierre

    2011-01-01

    Information and communication technology (ICT) becomes an important way for the knowledge transmission, especially in the field of medicine. Podcasting (mobile broadcast content) has recently emerged as an efficient tool for distributing information towards professionals, especially for e-learning contents.The goal of this work is to implement software and hardware tools for collecting medical lectures at its source by direct recording (halls and classrooms) and provide the automatic delivery of these resources for students on different type of devices (computer, smartphone or videogames console). We describe the overall architecture and the methods used by medical students to master this technology in their daily activities. We highlight the benefits and the limits of the Podcast technologies for medical education. PMID:21893751

  14. Visualization index for image-enabled medical records

    NASA Astrophysics Data System (ADS)

    Dong, Wenjie; Zheng, Weilin; Sun, Jianyong; Zhang, Jianguo

    2011-03-01

    With the widely use of healthcare information technology in hospitals, the patients' medical records are more and more complex. To transform the text- or image-based medical information into easily understandable and acceptable form for human, we designed and developed an innovation indexing method which can be used to assign an anatomical 3D structure object to every patient visually to store indexes of the patients' basic information, historical examined image information and RIS report information. When a doctor wants to review patient historical records, he or she can first load the anatomical structure object and the view the 3D index of this object using a digital human model tool kit. This prototype system helps doctors to easily and visually obtain the complete historical healthcare status of patients, including large amounts of medical data, and quickly locate detailed information, including both reports and images, from medical information systems. In this way, doctors can save time that may be better used to understand information, obtain a more comprehensive understanding of their patients' situations, and provide better healthcare services to patients.

  15. Diffusion of Electronic Medical Record Based Public Hospital Information Systems

    PubMed Central

    Cho, Kyoung Won; Kim, Seong Min; An, Chang-Ho

    2015-01-01

    Objectives This study was conducted to evaluate the adoption behavior of a newly developed Electronic Medical Record (EMR)-based information system (IS) at three public hospitals in Korea with a focus on doctors and nurses. Methods User satisfaction scores from four performance layers were analyzed before and two times after the newly develop system was introduced to evaluate the adoption process of the IS with Rogers' diffusion theory. Results The 'intention to use' scores, the most important indicator for determining whether or not to adopt the IS in Rogers' confirmation stage for doctors, were very high in the third survey (4.21). In addition, the scores for 'reduced medication errors', which is the key indicator for evaluating the success of the IS, increased in the third survey for both doctors and nurses. The factors influencing 'intention to use' with a high odds ratio (>1.5) were the 'frequency of attendance of user training sessions', 'mandatory use of system', 'reduced medication errors', and 'reduced medical record documentation time' for both doctors and nurses. Conclusions These findings show that the new EMR-based IS was well accepted by doctors. Both doctors and nurses also positively considered the effects of the new IS on their clinical environments. PMID:26279954

  16. The Regenstrief Medical Record System: a quarter century experience.

    PubMed

    McDonald, C J; Overhage, J M; Tierney, W M; Dexter, P R; Martin, D K; Suico, J G; Zafar, A; Schadow, G; Blevins, L; Glazener, T; Meeks-Johnson, J; Lemmon, L; Warvel, J; Porterfield, B; Warvel, J; Cassidy, P; Lindbergh, D; Belsito, A; Tucker, M; Williams, B; Wodniak, C

    1999-06-01

    Entrusted with the records for more than 1.5 million patients, the Regenstrief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana University Medical Center campus and more than 30 Indianapolis clinics. The RMRS routinely captures laboratory results, narrative reports, orders, medications, radiology reports, registration information, nursing assessments, vital signs, EKGs and other clinical data. In this paper, we describe the RMRS data model, file structures and architecture, as well as recent necessary changes to these as we coordinate a collaborative effort among all major Indianapolis hospital systems, improving patient care by capturing city-wide laboratory and encounter data. We believe that our success represents persistent efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOINC, and DICOM. Inpatient and outpatient order entry systems, instruments for visit notes and on-line questionnaires that replace hardcopy forms, and intelligent use of coded data entry supplement the RMRS. Physicians happily enter orders, problems, allergies, visit notes, and discharge summaries into our locally developed Gopher order entry system, as we provide them with convenient output forms, choice lists, defaults, templates, reminders, drug interaction information, charge information, and on-line articles and textbooks. To prepare for the future, we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employing wireless technology. PMID:10405881

  17. Data-driven approach for creating synthetic electronic medical records

    PubMed Central

    2010-01-01

    Background New algorithms for disease outbreak detection are being developed to take advantage of full electronic medical records (EMRs) that contain a wealth of patient information. However, due to privacy concerns, even anonymized EMRs cannot be shared among researchers, resulting in great difficulty in comparing the effectiveness of these algorithms. To bridge the gap between novel bio-surveillance algorithms operating on full EMRs and the lack of non-identifiable EMR data, a method for generating complete and synthetic EMRs was developed. Methods This paper describes a novel methodology for generating complete synthetic EMRs both for an outbreak illness of interest (tularemia) and for background records. The method developed has three major steps: 1) synthetic patient identity and basic information generation; 2) identification of care patterns that the synthetic patients would receive based on the information present in real EMR data for similar health problems; 3) adaptation of these care patterns to the synthetic patient population. Results We generated EMRs, including visit records, clinical activity, laboratory orders/results and radiology orders/results for 203 synthetic tularemia outbreak patients. Validation of the records by a medical expert revealed problems in 19% of the records; these were subsequently corrected. We also generated background EMRs for over 3000 patients in the 4-11 yr age group. Validation of those records by a medical expert revealed problems in fewer than 3% of these background patient EMRs and the errors were subsequently rectified. Conclusions A data-driven method was developed for generating fully synthetic EMRs. The method is general and can be applied to any data set that has similar data elements (such as laboratory and radiology orders and results, clinical activity, prescription orders). The pilot synthetic outbreak records were for tularemia but our approach may be adapted to other infectious diseases. The pilot synthetic

  18. Five benefits of call recording for medical practices.

    PubMed

    Murphy, Roland

    2010-01-01

    Despite documentation's essential positioning in medical practices of all sizes and specialties, one aspect of patient and insurance provider interaction remains overlooked in the majority of practices: telephone-based communication. In many cases, patient and payment information exchanged via telephone is logged with little more than a note typed or written in the patient file. This leads to "he said/she said" disagreements with regard to patient service, consultations, and coding; reduced payments from insurance providers; incomplete patient records; liability exposure; and a host of other problems. In this article, call recording professional Roland Murphy explains how a call recording solution can fill the gaps in documentation, increase practice revenues, and improve patient care without excessive investment costs and while protecting patient confidentiality. PMID:20480782

  19. Medical-concept models and medical records: an approach based on GALEN and PEN&PAD.

    PubMed Central

    Rector, A L; Glowinski, A J; Nowlan, W A; Rossi-Mori, A

    1995-01-01

    OBJECTIVES: To investigate the issues raised in applying a preliminary version of the GALEN compositional concept reference (CORE) model to a series of radiographic reports, and to demonstrate that the same underlying concept model could be used in conjunction with both a detailed, fine-grained model of medical records based on that used in the PEN&PAD project and with other more conventional medical-record models. DESIGN: Following analysis and representation of concepts from a set of reports, a single report was taken as a "case study." This report was analyzed in detail in its entirety and represented using each of the medical-record models. RESULTS: The reports were successfully represented within the limits of the study, but a number of significant issues were raised. CONCLUSION: The compositional approach plus the PEN&PAD medical-record model allowed detailed information in the radiographic report to be represented, including information about the inferences and the clinical process. The resulting representation was large, and more compact representations may be necessary for some systems. Alternative encapsulations of the information as might be used in such systems were successfully prepared. The compositional approach avoided many issues that often cause controversy in the design of traditional coding and classification systems, but it raised other issues, including the handling of ambiguity and underspecification, linkage to information not explicitly present in the report, and questions concerning the focus of individual concepts. All work is preliminary and definitive conclusions await further studies and systematic evaluation. PMID:7895133

  20. [Electronic medical records: medical and legal aspects, privacy, safety, and legal validity].

    PubMed

    Ravizza, P; Pasini, E

    2001-03-01

    Medical records must collect all data concerning in-hospital management of patients: data have to be verified and easily retrievable. Clinicians are responsible for both format and content of medical records. Respect of patient's privacy must be made sure both during on-line management and long-term storage of records. Computerization can offer many advantages to clinicians, but needs some significant adjustments: training and motivation of operators, arrangement of clinical processes and of administrative rules to technological developments. Nevertheless, some important results can be afforded: standardization of procedures, distribution of univocal, verified and ubiquitous data to all concerned operators, protection against undesired retrieval, reliability of effective reports. Preliminary condition is a clinical local area network, widespread into the institution. Database implementation must follow well accepted methodology: flow chart design of data dictionary, standardization of data coding, input of verified data, effective reporting. Access to data must be controlled by sophisticated and sure password system. Back-up of data must be automatically available with adequate timing and methodology. Respect of rules on patient's privacy must be realized whenever possible. Complex clinical records should be made available, containing data, signals and images (both single frames and dynamic sequences), due to continuous technical progress of diagnostic tools. Medical records must be available for long periods of time: database engine and managing tools must be selected among well accepted and largely available producers; informatic assistance must be assured for management and evolution of systems over the years. PMID:11307785

  1. A Pharmacy Blueprint for Electronic Medical Record Implementation Success

    PubMed Central

    Bach, David S.; Risko, Kenneth R.; Farber, Margo S.; Polk, Gregory J.

    2015-01-01

    Objective: Implementation of an integrated, electronic medical record (EMR) has been promoted as a means of improving patient safety and quality. While there are a few reports of such processes that incorporate computerized prescriber order entry, pharmacy verification, an electronic medication administration record (eMAR), point-of-care barcode scanning, and clinical decision support, there are no published reports on how a pharmacy department can best participate in implementing such a process across a multihospital health care system. Method: This article relates the experience of the design, build, deployment, and maintenance of an integrated EMR solution from the pharmacy perspective. It describes a 9-month planning and build phase and the subsequent rollout at 8 hospitals over the following 13 months. Results: Key components to success are identified, as well as a set of guiding principles that proved invaluable in decision making and dispute resolution. Labor/personnel requirements for the various stages of the process are discussed, as are issues involving medication workflow analysis, drug database considerations, the development of clinical order sets, and incorporation of bar-code scanning of medications. Recommended implementation and maintenance strategies are presented, and the impact of EMR implementation on the pharmacy practice model and revenue analysis are examined. Conclusion: Adherence to the principles and practices outlined in this article can assist pharmacy administrators and clinicians during all medication-related phases of the development, implementation, and maintenance of an EMR solution. Furthermore, review and incorporation of some or all of practices presented may help ease the process and ensure its success. PMID:26405340

  2. Automated de-identification of free-text medical records

    PubMed Central

    Neamatullah, Ishna; Douglass, Margaret M; Lehman, Li-wei H; Reisner, Andrew; Villarroel, Mauricio; Long, William J; Szolovits, Peter; Moody, George B; Mark, Roger G; Clifford, Gari D

    2008-01-01

    Background Text-based patient medical records are a vital resource in medical research. In order to preserve patient confidentiality, however, the U.S. Health Insurance Portability and Accountability Act (HIPAA) requires that protected health information (PHI) be removed from medical records before they can be disseminated. Manual de-identification of large medical record databases is prohibitively expensive, time-consuming and prone to error, necessitating automatic methods for large-scale, automated de-identification. Methods We describe an automated Perl-based de-identification software package that is generally usable on most free-text medical records, e.g., nursing notes, discharge summaries, X-ray reports, etc. The software uses lexical look-up tables, regular expressions, and simple heuristics to locate both HIPAA PHI, and an extended PHI set that includes doctors' names and years of dates. To develop the de-identification approach, we assembled a gold standard corpus of re-identified nursing notes with real PHI replaced by realistic surrogate information. This corpus consists of 2,434 nursing notes containing 334,000 words and a total of 1,779 instances of PHI taken from 163 randomly selected patient records. This gold standard corpus was used to refine the algorithm and measure its sensitivity. To test the algorithm on data not used in its development, we constructed a second test corpus of 1,836 nursing notes containing 296,400 words. The algorithm's false negative rate was evaluated using this test corpus. Results Performance evaluation of the de-identification software on the development corpus yielded an overall recall of 0.967, precision value of 0.749, and fallout value of approximately 0.002. On the test corpus, a total of 90 instances of false negatives were found, or 27 per 100,000 word count, with an estimated recall of 0.943. Only one full date and one age over 89 were missed. No patient names were missed in either corpus. Conclusion We have

  3. Cardiovascular disease documentation and counseling in electronic medical records.

    PubMed

    Bae, Jaeyong; Huerta, Timothy R; Ford, Eric W

    2016-07-01

    The purpose of this paper is to explore the relationship between clinical reminders generated by electronic medical record (EMR) systems and providers giving prevention counseling to patients at-risk for cardiovascular disease (CVD). Data were extracted from the 2012 National Ambulatory Medical Care Survey (NAMCS). Results indicate that the providers routinely using clinical reminders are significantly more likely to document height and weight data to determine risk and provide the recommended counseling to patients that merit the intervention. The findings are important for policymakers and managers that have been promoting the adoption of more sophisticated EMR decision support functionalities across the care delivery spectrum. In particular, the ability to intervene prior to negative health events is an important feature of the movement to improve care quality and reduce costs. PMID:27002255

  4. Special requirements for electronic medical records in neurology

    PubMed Central

    Longhurst, Christopher A.; Hahn, Jin S.

    2015-01-01

    Summary Electronic medical records (EMRs) are being rapidly adapted in the United States with goals of improving patient care, increasing efficiency, and reducing costs. Neurologists must become knowledgeable about the utility and effectiveness of the important parts of these systems specifically needed for care of neurology patients. The field of neurology encompasses complex disorders whose diagnosis and management heavily relies on detailed medical documentation of history and physical examination, and often on specialty-specific ancillary tests and extensive neuroimaging. Small discrepancies in documentation or absence of an in-hand ancillary test result can drastically change the current workup or treatment decision of a complex patient with neurologic disease. We describe current models and opportunities for improvements to EMRs that provide utility and efficiency in the care of neurology patients. PMID:25717421

  5. Reflecting on the ethical administration of computerized medical records

    NASA Astrophysics Data System (ADS)

    Collmann, Jeff R.

    1995-05-01

    This presentation examines the ethical issues raised by computerized image management and communication systems (IMAC), the ethical principals that should guide development of policies, procedures and practices for IMACS systems, and who should be involved in developing a hospital's approach to these issues. The ready access of computerized records creates special hazards of which hospitals must beware. Hospitals must maintain confidentiality of patient's records while making records available to authorized users as efficiently as possible. The general conditions of contemporary health care undermine protecting the confidentiality of patient record. Patients may not provide health care institutions with information about themselves under conditions of informed consent. The field of information science must design sophisticated systems of computer security that stratify access, create audit trails on data changes and system use, safeguard patient data from corruption, and protect the databases from outside invasion. Radiology professionals must both work with information science experts in their own hospitals to create institutional safeguards and include the adequacy of security measures as a criterion for evaluating PACS systems. New policies and procedures on maintaining computerized patient records must be developed that obligate all members of the health care staff, not just care givers. Patients must be informed about the existence of computerized medical records, the rules and practices that govern their dissemination and given the opportunity to give or withhold consent for their use. Departmental and hospital policies on confidentiality should be reviewed to determine if revisions are necessary to manage computer-based records. Well developed discussions of the ethical principles and administrative policies on confidentiality and informed consent and of the risks posed by computer-based patient records systems should be included in initial and continuing

  6. Identifying phenotypic signatures of neuropsychiatric disorders from electronic medical records

    PubMed Central

    Lyalina, Svetlana; Percha, Bethany; LePendu, Paea; Iyer, Srinivasan V; Altman, Russ B; Shah, Nigam H

    2013-01-01

    Objective Mental illness is the leading cause of disability in the USA, but boundaries between different mental illnesses are notoriously difficult to define. Electronic medical records (EMRs) have recently emerged as a powerful new source of information for defining the phenotypic signatures of specific diseases. We investigated how EMR-based text mining and statistical analysis could elucidate the phenotypic boundaries of three important neuropsychiatric illnesses—autism, bipolar disorder, and schizophrenia. Methods We analyzed the medical records of over 7000 patients at two facilities using an automated text-processing pipeline to annotate the clinical notes with Unified Medical Language System codes and then searching for enriched codes, and associations among codes, that were representative of the three disorders. We used dimensionality-reduction techniques on individual patient records to understand individual-level phenotypic variation within each disorder, as well as the degree of overlap among disorders. Results We demonstrate that automated EMR mining can be used to extract relevant drugs and phenotypes associated with neuropsychiatric disorders and characteristic patterns of associations among them. Patient-level analyses suggest a clear separation between autism and the other disorders, while revealing significant overlap between schizophrenia and bipolar disorder. They also enable localization of individual patients within the phenotypic ‘landscape’ of each disorder. Conclusions Because EMRs reflect the realities of patient care rather than idealized conceptualizations of disease states, we argue that automated EMR mining can help define the boundaries between different mental illnesses, facilitate cohort building for clinical and genomic studies, and reveal how clear expert-defined disease boundaries are in practice. PMID:23956017

  7. Application of an Electronic Medical Record in Space Medicine

    NASA Technical Reports Server (NTRS)

    McGinnis, Patrick J.

    2000-01-01

    Electronic Medical Records (EMR) have been emerging over the past decade. Today, they are replacing the paper chart in clinics throughout the nation. Approximately three years ago, the NASA-JSC Flight Medicine Clinic initiated an assessment of the EMRs available on the market. This assessment included comparing these products with the particular scope of practice at JSC. In 1998, the Logician EMR from Medicalogic was selected for the JSC Flight Medicine Clinic. This presentation reviews the process of selection and implementation of the EMR into the unique practice of aerospace medicine at JSC.

  8. Patient clustering with uncoded text in electronic medical records.

    PubMed

    Henao, Ricardo; Murray, Jared; Ginsburg, Geoffrey; Carin, Lawrence; Lucas, Joseph E

    2013-01-01

    We propose a mixture model for text data designed to capture underlying structure in the history of present illness section of electronic medical records data. Additionally, we propose a method to induce bias that leads to more homogeneous sets of diagnoses for patients in each cluster. We apply our model to a collection of electronic records from an emergency department and compare our results to three other relevant models in order to assess performance. Results using standard metrics demonstrate that patient clusters from our model are more homogeneous when compared to others, and qualitative analyses suggest that our approach leads to interpretable patient sub-populations when applied to real data. Finally, we demonstrate an example of our patient clustering model to identify adverse drug events. PMID:24551361

  9. Applying XDS for sharing CDA-based medical records

    NASA Astrophysics Data System (ADS)

    Kim, Joong Il; Jang, Bong Mun; Han, Dong Hoon; Yang, Keon Ho; Kang, Won-Suk; Jung, Haijo; Kim, Hee-Joung

    2006-03-01

    Many countries have set long-term objectives for establishing an Electronic Healthcare Records system(EHRs). Various IT Strategies note that integration of EHR systems has a high priority. Because the EHR systems are based on different information models and different technology platforms, one of the key integration problems in the realization of the EHRs for the continuity of patient care, is the inability to share patient records between various institutions. Integrating the Healthcare Enterprise (IHE) committee has defined the detailed implementations of existing standards such as DICOM, HL7, in a publicly available document called the IHE technical framework (IHE-TF). Cross-enterprise document sharing (XDS), one of IHE technical frameworks, is describing how to apply the standards into the information systems for the sharing of medical documents among hospitals. This study aims to design Clinical Document Architecture (CDA) schema based on HL7, and to apply implementation strategies of XDS using this CDA schema.

  10. Patient Clustering with Uncoded Text in Electronic Medical Records

    PubMed Central

    Henao, Ricardo; Murray, Jared; Ginsburg, Geoffrey; Carin, Lawrence; Lucas, Joseph E.

    2013-01-01

    We propose a mixture model for text data designed to capture underlying structure in the history of present illness section of electronic medical records data. Additionally, we propose a method to induce bias that leads to more homogeneous sets of diagnoses for patients in each cluster. We apply our model to a collection of electronic records from an emergency department and compare our results to three other relevant models in order to assess performance. Results using standard metrics demonstrate that patient clusters from our model are more homogeneous when compared to others, and qualitative analyses suggest that our approach leads to interpretable patient sub-populations when applied to real data. Finally, we demonstrate an example of our patient clustering model to identify adverse drug events. PMID:24551361

  11. A Curriculum Guide for Medical Record Education. Educational Resource Document. October 1, 1980- December 31, 1981.

    ERIC Educational Resources Information Center

    Biglow, Laura Anne; File, Christine E.

    This curriculum guide consists of guidelines and materials for use in developing a competency-based medical record education course for students in a medical record administration or technician program. Covered in the individual chapters are curriculum design; the role and responsibilities of medical record practitioners; the affective domain and…

  12. The Design & Implementation of a Curriculum Ladder in Medical Record Administration 1970-1973.

    ERIC Educational Resources Information Center

    Waters, Kathleen A.; Hanken, Mary Alice

    Objectives of a 3-year articulation project were (1) to design and put into effect a curriculum for medical record personnel which would provide educational progression for associate arts degree medical record technicians to baccalaureate degree medical record administration programs, (2) to research, classify, and compare curriculum content of…

  13. 32 CFR 310.24 - Disclosures to the public from medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 2 2012-07-01 2012-07-01 false Disclosures to the public from medical records... Agencies and Third Parties § 310.24 Disclosures to the public from medical records. (a) Disclosures from medical records are not only governed by the requirement of this part but also by the...

  14. 42 CFR 480.131 - Access to medical records for the monitoring of QIOs.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 4 2011-10-01 2011-10-01 false Access to medical records for the monitoring of... Improvement Organizations (QIOs) Disclosure of Confidential Information § 480.131 Access to medical records... Federal statute to monitor a QIO will have access to medical records maintained by institutions or...

  15. 29 CFR 2400.7 - Special procedures for requesting medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 29 Labor 9 2012-07-01 2012-07-01 false Special procedures for requesting medical records. 2400.7... COMMISSION REGULATIONS IMPLEMENTING THE PRIVACY ACT § 2400.7 Special procedures for requesting medical records. (a) Upon an individual's request for access to his medical records, including...

  16. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... and Medical Records. 513.44 Section 513.44 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... Institution for Information § 513.44 Fees for copies of Inmate Central File and Medical Records. Within a... disclosable documents maintained in the Inmate Central File and Medical Record. Fees for the copies are to...

  17. 29 CFR 2400.7 - Special procedures for requesting medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 9 2011-07-01 2011-07-01 false Special procedures for requesting medical records. 2400.7... COMMISSION REGULATIONS IMPLEMENTING THE PRIVACY ACT § 2400.7 Special procedures for requesting medical records. (a) Upon an individual's request for access to his medical records, including...

  18. 77 FR 42555 - Proposed Information Collection (Request for and Authorization To Release Medical Records or...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-19

    ... AFFAIRS Proposed Information Collection (Request for and Authorization To Release Medical Records or... solicits comments on information needed to obtain a patient written consent to disclose medical records or... Medical Records or Health Information, VA Form 10-5345. b. Individual's Request for a Copy of their...

  19. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... and Medical Records. 513.44 Section 513.44 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... Institution for Information § 513.44 Fees for copies of Inmate Central File and Medical Records. Within a... disclosable documents maintained in the Inmate Central File and Medical Record. Fees for the copies are to...

  20. 42 CFR 480.131 - Access to medical records for the monitoring of QIOs.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Access to medical records for the monitoring of... Improvement Organizations (QIOs) Disclosure of Confidential Information § 480.131 Access to medical records... Federal statute to monitor a QIO will have access to medical records maintained by institutions or...

  1. 32 CFR 806b.17 - Special provision for certain medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 6 2013-07-01 2013-07-01 false Special provision for certain medical records. 806b.17 Section 806b.17 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE... medical records. If a physician believes that disclosing requested medical records could harm the...

  2. 32 CFR 806b.17 - Special provision for certain medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 6 2011-07-01 2011-07-01 false Special provision for certain medical records. 806b.17 Section 806b.17 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE... medical records. If a physician believes that disclosing requested medical records could harm the...

  3. 29 CFR 2400.7 - Special procedures for requesting medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 9 2010-07-01 2010-07-01 false Special procedures for requesting medical records. 2400.7... COMMISSION REGULATIONS IMPLEMENTING THE PRIVACY ACT § 2400.7 Special procedures for requesting medical records. (a) Upon an individual's request for access to his medical records, including...

  4. 32 CFR 310.24 - Disclosures to the public from medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 2 2013-07-01 2013-07-01 false Disclosures to the public from medical records... Agencies and Third Parties § 310.24 Disclosures to the public from medical records. (a) Disclosures from medical records are not only governed by the requirement of this part but also by the...

  5. 29 CFR 2400.7 - Special procedures for requesting medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 29 Labor 9 2013-07-01 2013-07-01 false Special procedures for requesting medical records. 2400.7... COMMISSION REGULATIONS IMPLEMENTING THE PRIVACY ACT § 2400.7 Special procedures for requesting medical records. (a) Upon an individual's request for access to his medical records, including...

  6. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... and Medical Records. 513.44 Section 513.44 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... Institution for Information § 513.44 Fees for copies of Inmate Central File and Medical Records. Within a... disclosable documents maintained in the Inmate Central File and Medical Record. Fees for the copies are to...

  7. 32 CFR 310.24 - Disclosures to the public from medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Disclosures to the public from medical records... Agencies and Third Parties § 310.24 Disclosures to the public from medical records. (a) Disclosures from medical records are not only governed by the requirement of this part but also by the...

  8. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... and Medical Records. 513.44 Section 513.44 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... Institution for Information § 513.44 Fees for copies of Inmate Central File and Medical Records. Within a... disclosable documents maintained in the Inmate Central File and Medical Record. Fees for the copies are to...

  9. 42 CFR 416.47 - Condition for coverage-Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 3 2011-10-01 2011-10-01 false Condition for coverage-Medical records. 416.47....47 Condition for coverage—Medical records. The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care. (a) Standard: Organization. The ASC must...

  10. 28 CFR 513.44 - Fees for copies of Inmate Central File and Medical Records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... and Medical Records. 513.44 Section 513.44 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF... Institution for Information § 513.44 Fees for copies of Inmate Central File and Medical Records. Within a... disclosable documents maintained in the Inmate Central File and Medical Record. Fees for the copies are to...

  11. 42 CFR 480.131 - Access to medical records for the monitoring of QIOs.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Access to medical records for the monitoring of... Improvement Organizations (QIOs) Disclosure of Confidential Information § 480.131 Access to medical records... Federal statute to monitor a QIO will have access to medical records maintained by institutions or...

  12. 32 CFR 806b.17 - Special provision for certain medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 6 2014-07-01 2014-07-01 false Special provision for certain medical records. 806b.17 Section 806b.17 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE... medical records. If a physician believes that disclosing requested medical records could harm the...

  13. 42 CFR 416.47 - Condition for coverage-Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 3 2013-10-01 2013-10-01 false Condition for coverage-Medical records. 416.47... Coverage § 416.47 Condition for coverage—Medical records. The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care. (a) Standard: Organization. The ASC...

  14. 32 CFR 310.24 - Disclosures to the public from medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 2 2011-07-01 2011-07-01 false Disclosures to the public from medical records... Agencies and Third Parties § 310.24 Disclosures to the public from medical records. (a) Disclosures from medical records are not only governed by the requirement of this part but also by the...

  15. 32 CFR 806b.17 - Special provision for certain medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Special provision for certain medical records. 806b.17 Section 806b.17 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE... medical records. If a physician believes that disclosing requested medical records could harm the...

  16. 32 CFR 806b.17 - Special provision for certain medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 6 2012-07-01 2012-07-01 false Special provision for certain medical records. 806b.17 Section 806b.17 National Defense Department of Defense (Continued) DEPARTMENT OF THE AIR FORCE... medical records. If a physician believes that disclosing requested medical records could harm the...

  17. 42 CFR 480.131 - Access to medical records for the monitoring of QIOs.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Access to medical records for the monitoring of... Improvement Organizations (QIOs) Disclosure of Confidential Information § 480.131 Access to medical records... Federal statute to monitor a QIO will have access to medical records maintained by institutions or...

  18. 32 CFR 310.24 - Disclosures to the public from medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 2 2014-07-01 2014-07-01 false Disclosures to the public from medical records... Agencies and Third Parties § 310.24 Disclosures to the public from medical records. (a) Disclosures from medical records are not only governed by the requirement of this part but also by the...

  19. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 32 National Defense 6 2012-07-01 2012-07-01 false Special procedures for medical and psychological... Special procedures for medical and psychological records. (a) In general. When a request for access or amendment involves medical or psychological records and when the originator determines that such records...

  20. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 32 National Defense 6 2014-07-01 2014-07-01 false Special procedures for medical and psychological... Special procedures for medical and psychological records. (a) In general. When a request for access or amendment involves medical or psychological records and when the originator determines that such records...

  1. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management... for medical/psychological records. (a) The Executive Director may require an individual who requests access to his medical or psychological record to designate a physician of his choice to whom he...

  2. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management... for medical/psychological records. (a) The Executive Director may require an individual who requests access to his medical or psychological record to designate a physician of his choice to whom he...

  3. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management... for medical/psychological records. (a) The Executive Director may require an individual who requests access to his medical or psychological record to designate a physician of his choice to whom he...

  4. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 32 National Defense 6 2013-07-01 2013-07-01 false Special procedures for medical and psychological... Special procedures for medical and psychological records. (a) In general. When a request for access or amendment involves medical or psychological records and when the originator determines that such records...

  5. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 6 2011-07-01 2011-07-01 false Special procedures for medical and psychological... Special procedures for medical and psychological records. (a) In general. When a request for access or amendment involves medical or psychological records and when the originator determines that such records...

  6. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management... for medical/psychological records. (a) The Executive Director may require an individual who requests access to his medical or psychological record to designate a physician of his choice to whom he...

  7. 41 CFR 51-9.303-2 - Special requirements for medical/psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... medical/psychological records. 51-9.303-2 Section 51-9.303-2 Public Contracts and Property Management... for medical/psychological records. (a) The Executive Director may require an individual who requests access to his medical or psychological record to designate a physician of his choice to whom he...

  8. 12 CFR 792.57 - Special procedures: Information furnished by other agencies; medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... other agencies; medical records. 792.57 Section 792.57 Banks and Banking NATIONAL CREDIT UNION...; medical records. (a) When a request for records or information from NCUA includes information furnished by... records may be disclosed on request to the individuals to whom they pertain unless disclosing the...

  9. 12 CFR 792.57 - Special procedures: Information furnished by other agencies; medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... other agencies; medical records. 792.57 Section 792.57 Banks and Banking NATIONAL CREDIT UNION...; medical records. (a) When a request for records or information from NCUA includes information furnished by... records may be disclosed on request to the individuals to whom they pertain unless disclosing the...

  10. 12 CFR 792.57 - Special procedures: Information furnished by other agencies; medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... other agencies; medical records. 792.57 Section 792.57 Banks and Banking NATIONAL CREDIT UNION...; medical records. (a) When a request for records or information from NCUA includes information furnished by... records may be disclosed on request to the individuals to whom they pertain unless disclosing the...

  11. 12 CFR 792.57 - Special procedures: Information furnished by other agencies; medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... other agencies; medical records. 792.57 Section 792.57 Banks and Banking NATIONAL CREDIT UNION...; medical records. (a) When a request for records or information from NCUA includes information furnished by... records may be disclosed on request to the individuals to whom they pertain unless disclosing the...

  12. 12 CFR 792.57 - Special procedures: Information furnished by other agencies; medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... other agencies; medical records. 792.57 Section 792.57 Banks and Banking NATIONAL CREDIT UNION...; medical records. (a) When a request for records or information from NCUA includes information furnished by... records may be disclosed on request to the individuals to whom they pertain unless disclosing the...

  13. Relevance of the electronic computer to hospital medical records*

    PubMed Central

    Mitchell, J. H.

    1969-01-01

    During the past 30 years an “information explosion” has completely changed patterns of illness. Unit files of individual patients have become so large that they are increasingly difficult both to store physically and to assimilate mentally. We have reached a communications barriers which poses a major threat to the efficient practice of clinical medicine. At the same time a new kind of machine, the electronic digital computer, which was invented only 26 years ago, has already come to dominate large areas of military, scientific, commercial, and industrial activity. Its supremacy rests on its ability to perform any data procedure automatically and incredibly quickly. Computers are being employed in clinical medicine in hospitals for various purposes. They can act as arithmetic calculators, they can process and analyse output from recording devices, and they can make possible the automation of various machine systems. However, in the field of case records their role is much less well defined, for here the organization of data as a preliminary to computer input is the real stumbling-block. Data banks of retrospective selected clinical information have been in operation in some centres for a number of years. Attempts are now being made to design computerized “total information systems” to replace conventional paper records, and the possibility of automated diagnosis is being seriously discussed. In my view, however, the medical profession is in danger of being dazzled by optimistic claims about the usefulness of computers in case record processing. The solution to the present problems of record storage and handling is very simple, and does not involve computerization. PMID:4898564

  14. Use of Electronic Medication Administration Records to Reduce Perceived Stress and Risk of Medication Errors in Nursing Homes.

    PubMed

    Alenius, Malin; Graf, Peter

    2016-07-01

    Concerns have been raised about the effects of current medication administration processes on the safety of many of the aspects of medication administration. Keeping electronic medication administration records could decrease many of these problems. Unfortunately, there has not been much research on this topic, especially in nursing homes. A prospective case-control survey was consequently performed at two nursing homes; the electronic record system was introduced in one, whereas the other continued to use paper records. The personnel were asked to fill in a questionnaire of their perceptions of stress and risk of medication errors at baseline (n = 66) and 20 weeks after the intervention group had started recording medication administration electronically (n = 59). There were statistically significant decreases in the perceived risk of omitting a medication, of medication errors occurring because of communication problems, and of medication errors occurring because of inaccurate medication administration records in the intervention group (all P < .01 vs the control group). The perceived overall daily stress levels were also reduced in the intervention group (P < .05). These results indicate that the utilization of electronic medication administration records will reduce many of the concerns regarding the medication administration process. PMID:27270628

  15. A clinical trial of a knowledge-based medical record.

    PubMed

    Safran, C; Rind, D M; Davis, R B; Sands, D Z; Caraballo, E; Rippel, K; Wang, Q; Rury, C; Makadon, H J; Cotton, D J

    1995-01-01

    To meet the needs of primary care physicians caring for patients with HIV infection, we developed a knowledge-based medical record to allow the on-line patient record to play an active role in the care process. These programs integrate the on-line patient record, rule-based decision support, and full-text information retrieval into a clinical workstation for the practicing clinician. To determine whether use of a knowledge-based medical record was associated with more rapid and complete adherence to practice guidelines and improved quality of care, we performed a controlled clinical trial among physicians and nurse practitioners caring for 349 patients infected with the human immuno-deficiency virus (HIV); 191 patients were treated by 65 physicians and nurse practitioners assigned to the intervention group, and 158 patients were treated by 61 physicians and nurse practitioners assigned to the control group. During the 18-month study period, the computer generated 303 alerts in the intervention group and 388 in the control group. The median response time of clinicians to these alerts was 11 days in the intervention group and 52 days in the control group (PJJ0.0001, log-rank test). During the study, the computer generated 432 primary care reminders for the intervention group and 360 reminders for the control group. The median response time of clinicians to these alerts was 114 days in the intervention group and more than 500 days in the control group (PJJ0.0001, log-rank test). Of the 191 patients in the intervention group, 67 (35%) had one or more hospitalizations, compared with 70 (44%) of the 158 patients in the control group (PJ=J0.04, Wilcoxon test stratified for initial CD4 count). There was no difference in survival between the intervention and control groups (P = 0.18, log-rank test). We conclude that our clinical workstation significantly changed physicians' behavior in terms of their response to alerts regarding primary care interventions and that these

  16. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  17. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  18. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  19. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  20. 38 CFR 1.513 - Disclosure of information contained in Armed Forces service and related medical records in...

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... contained in Armed Forces service and related medical records in Department of Veterans Affairs custody. 1... information contained in Armed Forces service and related medical records in Department of Veterans Affairs.... (b) Medical records. Information contained in the medical records (including clinical records...

  1. Implementing electronic medical record systems in developing countries.

    PubMed

    Fraser, Hamish S F; Biondich, Paul; Moodley, Deshen; Choi, Sharon; Mamlin, Burke W; Szolovits, Peter

    2005-01-01

    The developing world faces a series of health crises including HIV/AIDS and tuberculosis that threaten the lives of millions of people. Lack of infrastructure and trained, experienced staff are considered important barriers to scaling up treatment for these diseases. In this paper we explain why information systems are important in many healthcare projects in the developing world. We discuss pilot projects demonstrating that such systems are possible and can expand to manage hundreds of thousands of patients. We also pass on the most important practical lessons in design and implementation from our experience in doing this work. Finally, we discuss the importance of collaboration between projects in the development of electronic medical record systems rather than reinventing systems in isolation, and the use of open standards and open source software. PMID:15992493

  2. Role prediction using Electronic Medical Record system audits.

    PubMed

    Zhang, Wen; Gunter, Carl A; Liebovitz, David; Tian, Jian; Malin, Bradley

    2011-01-01

    Electronic Medical Records (EMRs) provide convenient access to patient data for parties who should have it, but, unless managed properly, may also provide it to those who should not. Distinguishing the two is a core security challenge for EMRs. Strategies proposed to address these problems include Role Based Access Control (RBAC), which assigns collections of privileges called roles to users, and Experience Based Access Management (EBAM), which analyzes audit logs to determine access rights. In this paper, we integrate RBAC and EBAM through an algorithm, called Roll-Up, to manage roles effectively. In doing so, we introduce the concept of "role prediction" to identify roles from audit data. We apply the algorithm to three months of logs from Northwestern Memorial Hospital's Cerner system with approximately 8000 users and 140 roles. We demonstrate that existing roles can be predicted with 50% accuracy and intelligent grouping of roles through Roll-Up can facilitate 65% accuracy. PMID:22195144

  3. Forward secure digital signature for electronic medical records.

    PubMed

    Yu, Yao-Chang; Huang, To-Yeh; Hou, Ting-Wei

    2012-04-01

    The Technology Safeguard in Health Insurance Portability and Accountability Act (HIPAA) Title II has addressed a way to maintain the integrity and non-repudiation of Electronic Medical Record (EMR). One of the important cryptographic technologies is mentioned in the ACT is digital signature; however, the ordinary digital signature (e.g. DSA, RSA, GQ...) has an inherent weakness: if the key (certificate) is updated, than all signatures, even the ones generated before the update, are no longer trustworthy. Unfortunately, the current most frequently used digital signature schemes are categorized into the ordinary digital signature scheme; therefore, the objective of this paper is to analyze the shortcoming of using ordinary digital signatures in EMR and to propose a method to use forward secure digital signature to sign EMR to ensure that the past EMR signatures remain trustworthy while the key (certificate) is updated. PMID:20703711

  4. Factors Affecting Accuracy of Data Abstracted from Medical Records

    PubMed Central

    Zozus, Meredith N.; Pieper, Carl; Johnson, Constance M.; Johnson, Todd R.; Franklin, Amy; Smith, Jack; Zhang, Jiajie

    2015-01-01

    Objective Medical record abstraction (MRA) is often cited as a significant source of error in research data, yet MRA methodology has rarely been the subject of investigation. Lack of a common framework has hindered application of the extant literature in practice, and, until now, there were no evidence-based guidelines for ensuring data quality in MRA. We aimed to identify the factors affecting the accuracy of data abstracted from medical records and to generate a framework for data quality assurance and control in MRA. Methods Candidate factors were identified from published reports of MRA. Content validity of the top candidate factors was assessed via a four-round two-group Delphi process with expert abstractors with experience in clinical research, registries, and quality improvement. The resulting coded factors were categorized into a control theory-based framework of MRA. Coverage of the framework was evaluated using the recent published literature. Results Analysis of the identified articles yielded 292 unique factors that affect the accuracy of abstracted data. Delphi processes overall refuted three of the top factors identified from the literature based on importance and five based on reliability (six total factors refuted). Four new factors were identified by the Delphi. The generated framework demonstrated comprehensive coverage. Significant underreporting of MRA methodology in recent studies was discovered. Conclusion The framework generated from this research provides a guide for planning data quality assurance and control for studies using MRA. The large number and variability of factors indicate that while prospective quality assurance likely increases the accuracy of abstracted data, monitoring the accuracy during the abstraction process is also required. Recent studies reporting research results based on MRA rarely reported data quality assurance or control measures, and even less frequently reported data quality metrics with research results. Given

  5. Factors in Medical Student Beliefs about Electronic Health Record Use

    PubMed Central

    Harle, Christopher A.; Gruber, Laura A.; Dewar, Marvin A.

    2014-01-01

    Healthcare providers’ ongoing investment in electronic health records (EHRs) necessitates an understanding of physicians’ expectations about using EHRs. Such understanding may aid educators and administrators when utilizing scarce resources during EHR training and implementation activities. This study aimed to link individual medical student characteristics to their perceptions of EHRs’ ease of use and usefulness. This study employed a cross-sectional survey of 126 third-year medical students at a large southeastern university. Using a questionnaire designed for this study and containing previously validated items, the study team measured and related students’ expectations about EHR ease of use and usefulness to their computer self-efficacy, openness to change, personality traits, and demographic characteristics. On a seven-point scale, men reported, on average, ease-of-use scores that were 0.71 higher than women's (p < .001). Also, increased computer self-efficacy related to higher expectations of EHR ease of use (p < .01) and usefulness (p < .05). Openness-to-change scores were also associated with higher expectations of EHR ease of use (p < .01) and usefulness (p < .001). Finally, a more conscientious personality was positively associated with EHR ease of use (p < .01). Our findings suggest that medical educators and administrators may consider targeting EHR management strategies on the basis of individual differences. Enhanced training and support interventions may be helpful to women or to clinicians with lower computer self-efficacy, lower openness to change, or less conscientious personalities. Also, current and future physicians who rate higher in terms of self-efficacy, openness to change, or conscientiousness may be useful as champions of EHR use among their peers. PMID:24808813

  6. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... medical use. 35.2063 Section 35.2063 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2063 Records of dosages of unsealed byproduct material for medical use. (a) A... must contain— (1) The radiopharmaceutical; (2) The patient's or human research subject's name,...

  7. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... medical use. 35.2063 Section 35.2063 Energy NUCLEAR REGULATORY COMMISSION MEDICAL USE OF BYPRODUCT MATERIAL Records § 35.2063 Records of dosages of unsealed byproduct material for medical use. (a) A... must contain— (1) The radiopharmaceutical; (2) The patient's or human research subject's name,...

  8. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... to medical records. 5b.6 Section 5b.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION PRIVACY ACT REGULATIONS § 5b.6 Special procedures for notification of or access to medical records. (a) General. An individual in general has a right to notification of or access to his medical...

  9. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... to medical records. 5b.6 Section 5b.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION PRIVACY ACT REGULATIONS § 5b.6 Special procedures for notification of or access to medical records. (a) General. An individual in general has a right to notification of or access to his medical...

  10. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... to medical records. 5b.6 Section 5b.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION PRIVACY ACT REGULATIONS § 5b.6 Special procedures for notification of or access to medical records. (a) General. An individual in general has a right to notification of or access to his medical...

  11. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... to medical records. 5b.6 Section 5b.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION PRIVACY ACT REGULATIONS § 5b.6 Special procedures for notification of or access to medical records. (a) General. An individual in general has a right to notification of or access to his medical...

  12. Embracing the Sparse, Noisy, and Interrelated Aspects of Patient Demographics for use in Clinical Medical Record Linkage

    PubMed Central

    Ash, Stephen M.; Ip-Lin, King

    2015-01-01

    Duplicate patient records in health information systems have received increased attention in recent time due to regulatory incentives to integrate the healthcare enterprise. Historically, most patient record matching systems have been limited to simple applications of the Fellegi-Sunter theory of record linkage with edit distance based string similarity measurements. String similarity approaches ignore the rich semantic information present by reducing it to a simple syntactic comparison of characters. This work describes an updated approach to building clinical medical record linkage systems, which embraces the unavoidable problems present in real-world patient matching. Using a ground truth dataset of a real patient population, we demonstrate that systems built in this fashion improve recall by 76% with little reduction in precision. This result empirically demonstrates the size of the gap between sophisticated systems and naïve approaches. Additionally, it accentuates the difficulty in estimating the false negative error in this setting as previous research has reported much higher levels of recall, due, in part, to measuring from biased samples. PMID:26306279

  13. Embracing the Sparse, Noisy, and Interrelated Aspects of Patient Demographics for use in Clinical Medical Record Linkage.

    PubMed

    Ash, Stephen M; Ip-Lin, King

    2015-01-01

    Duplicate patient records in health information systems have received increased attention in recent time due to regulatory incentives to integrate the healthcare enterprise. Historically, most patient record matching systems have been limited to simple applications of the Fellegi-Sunter theory of record linkage with edit distance based string similarity measurements. String similarity approaches ignore the rich semantic information present by reducing it to a simple syntactic comparison of characters. This work describes an updated approach to building clinical medical record linkage systems, which embraces the unavoidable problems present in real-world patient matching. Using a ground truth dataset of a real patient population, we demonstrate that systems built in this fashion improve recall by 76% with little reduction in precision. This result empirically demonstrates the size of the gap between sophisticated systems and naïve approaches. Additionally, it accentuates the difficulty in estimating the false negative error in this setting as previous research has reported much higher levels of recall, due, in part, to measuring from biased samples. PMID:26306279

  14. Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center

    PubMed Central

    Rizer, Milisa K.; Kaufman, Beth; Sieck, Cynthia J.; Hefner, Jennifer L.; McAlearney, Ann Scheck

    2015-01-01

    Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple specialties providing inpatient and outpatient care. This case report provides an example of a successful EMR implementation that emphasizes the importance of flexibility and adaptability on the part of the implementation team. It also presents the top 10 lessons learned from this EMR implementation in a large midwestern academic medical center. Included are five overarching lessons related to leadership, initial approach, training, support, and optimization as well as five lessons related to the EMR system itself that are particularly important elements of a successful implementation. PMID:26396558

  15. Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center.

    PubMed

    Rizer, Milisa K; Kaufman, Beth; Sieck, Cynthia J; Hefner, Jennifer L; McAlearney, Ann Scheck

    2015-01-01

    Electronic medical record (EMR) implementation efforts face many challenges, including individual and organizational barriers and concerns about loss of productivity during the process. These issues may be particularly complex in large and diverse settings with multiple specialties providing inpatient and outpatient care. This case report provides an example of a successful EMR implementation that emphasizes the importance of flexibility and adaptability on the part of the implementation team. It also presents the top 10 lessons learned from this EMR implementation in a large midwestern academic medical center. Included are five overarching lessons related to leadership, initial approach, training, support, and optimization as well as five lessons related to the EMR system itself that are particularly important elements of a successful implementation. PMID:26396558

  16. 32 CFR 326.11 - Special procedures for disclosure of medical and psychological records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... psychological records. 326.11 Section 326.11 National Defense Department of Defense (Continued) OFFICE OF THE... Special procedures for disclosure of medical and psychological records. When requested medical and psychological records are not exempt from disclosure, the PA Coordinator may determine which non-exempt...

  17. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    .../psychological records. 1701.13 Section 1701.13 National Defense Other Regulations Relating to National Defense... procedures for medical/psychiatric/psychological records. Current and former ODNI employees, including... access to their medical, psychiatric or psychological testing records by writing to: Information...

  18. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    .../psychological records. 1701.13 Section 1701.13 National Defense Other Regulations Relating to National Defense... procedures for medical/psychiatric/psychological records. Current and former ODNI employees, including... access to their medical, psychiatric or psychological testing records by writing to: Information...

  19. 32 CFR 326.11 - Special procedures for disclosure of medical and psychological records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... psychological records. 326.11 Section 326.11 National Defense Department of Defense (Continued) OFFICE OF THE... Special procedures for disclosure of medical and psychological records. When requested medical and psychological records are not exempt from disclosure, the PA Coordinator may determine which non-exempt...

  20. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    .../psychological records. 1701.13 Section 1701.13 National Defense Other Regulations Relating to National Defense... procedures for medical/psychiatric/psychological records. Current and former ODNI employees, including... access to their medical, psychiatric or psychological testing records by writing to: Information...

  1. 32 CFR 326.11 - Special procedures for disclosure of medical and psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... psychological records. 326.11 Section 326.11 National Defense Department of Defense (Continued) OFFICE OF THE... Special procedures for disclosure of medical and psychological records. When requested medical and psychological records are not exempt from disclosure, the PA Coordinator may determine which non-exempt...

  2. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    .../psychological records. 1701.13 Section 1701.13 National Defense Other Regulations Relating to National Defense... procedures for medical/psychiatric/psychological records. Current and former ODNI employees, including... access to their medical, psychiatric or psychological testing records by writing to: Information...

  3. 32 CFR 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    .../psychological records. 1701.13 Section 1701.13 National Defense Other Regulations Relating to National Defense... procedures for medical/psychiatric/psychological records. Current and former ODNI employees, including... access to their medical, psychiatric or psychological testing records by writing to: Information...

  4. 32 CFR 326.11 - Special procedures for disclosure of medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... psychological records. 326.11 Section 326.11 National Defense Department of Defense (Continued) OFFICE OF THE... Special procedures for disclosure of medical and psychological records. When requested medical and psychological records are not exempt from disclosure, the PA Coordinator may determine which non-exempt...

  5. 32 CFR 326.11 - Special procedures for disclosure of medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... psychological records. 326.11 Section 326.11 National Defense Department of Defense (Continued) OFFICE OF THE... Special procedures for disclosure of medical and psychological records. When requested medical and psychological records are not exempt from disclosure, the PA Coordinator may determine which non-exempt...

  6. Patients Reading Their Medical Records: Differences in Experiences and Attitudes between Regular and Inexperienced Readers

    ERIC Educational Resources Information Center

    Huvila, Isto; Daniels, Mats; Cajander, Åsa; Åhlfeldt, Rose-Mharie

    2016-01-01

    Introduction: We report results of a study of how ordering and reading of printouts of medical records by regular and inexperienced readers relate to how the records are used, to the health information practices of patients, and to their expectations of the usefulness of new e-Health services and online access to medical records. Method: The study…

  7. 75 FR 1446 - Rate of Payment for Medical Records Received Through Health Information Technology (IT) Necessary...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-01-11

    ... ADMINISTRATION Rate of Payment for Medical Records Received Through Health Information Technology (IT) Necessary... national rate of Federal payment for medical records received through health IT. SUMMARY: We have set $15... records through health IT in response to a request. We will pay the uniform national rate to a...

  8. Ocular findings associated with chromosome 22q11.2 duplication.

    PubMed

    Forbes, Brian J; McDonald-McGinn, Donna M; Wootton, Georgia; Dawson, Lindsay; Zackai, Elaine; Binenbaum, Gil

    2016-06-01

    We describe the ocular features of the chromosome 22q11.2 duplication syndrome and provide ophthalmologic examination recommendations for affected patients. The medical records of 19 children with chromosome 22q11.2 duplication who had undergone complete ophthalmological examination, including dilated fundus examination and cycloplegic refraction, were studied retrospectively. Over half of the children with 22q11.2 duplication syndrome were found to have visually significant ocular abnormalities, including 6 with strabismus, 2 with moderately high astigmatism requiring glasses, 1 with unilateral congenital cataract requiring surgery, 1 with optic disk drusen, 1 with bilateral megalocornea with normal eye pressures, 1 with nystagmus that resolved spontaneously, and 1 with delayed visual maturation. Because of the high incidence of conditions that could affect visual development, we recommend that children with 22q11.2 duplication syndrome have a complete ophthalmological examination on diagnosis and regular vision screenings by their primary care physician thereafter. PMID:27108843

  9. 5 CFR 293.505 - Establishment and protection of Employee Medical Folder.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... the employee leaves the employing agency and occupational medical records for that employee exist... able to ascertain from agency implementing instructions the location of all of their medical records...) Neither the original occupational medical record nor duplicates are to be retained in the OPF. Prior...

  10. 5 CFR 293.505 - Establishment and protection of Employee Medical Folder.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... the employee leaves the employing agency and occupational medical records for that employee exist... able to ascertain from agency implementing instructions the location of all of their medical records...) Neither the original occupational medical record nor duplicates are to be retained in the OPF. Prior...

  11. [A Research on the origin and development of standardization of Chinese medical case records].

    PubMed

    Zhang, Lei

    2014-11-01

    The origin of Chinese medical case history is rather early. Chunyu Yi's medical cases (zhen ji) of the Western Han Dynasty were the earliest actual extant medical case with the practical contents. In the Ming Dynasty, Han Mao put forward firstly the principles of "six aspects must be recorded" for writing the pulse record, as the beginning of the standardization of medical case record. Later, Wu Kun, Yu Yan, Li Yanzhen, He Lianchen et al. supplemented, adjusted and changed the format of medical case record. After 1949, the format of medical case record was revised several times to form the national standard. In fact, the clinical medical case record is different from the case history. The modern medical case record could not reflect fully the thinking process of traditional Chinese medicine (TCM) and the essence of the treatment based on syndrome differentiation. Exploring the origin and development of the standardization of medical case record will benefit for the improvement of modern format of medical case record. PMID:25620355

  12. IMASIS computer-based medical record project: dealing with the human factor.

    PubMed

    Martín-Baranera, M; Planas, I; Palau, J; Sanz, F

    1995-01-01

    level, problems to be solved in utilization of the system, errors detected in the systems' database, and the personal interest in participating in the IMASIS project. The questionnaire was also intended to be a tool to monitor IMASIS evolution. Our study showed that medical staff had a lack of information about the current HIS, leading to a poor utilization of some system options. Another major characteristic, related to the above, was the feeling that the project would negatively affect the organization of work at the hospitals. A computer-based medical record was feared to degrade physician-patient relationship, introduce supplementary administrative burden in clinicians day-to-day work, unnecessarily slow history taking, and imply too-rigid patterns of work. The most frequent problems in using the current system could be classified into two groups: problems related to lack of agility and consistency in user interface design, and those derived from lack of a common patient identification number. Duplication of medical records was the most frequent error detected by physicians. Analysis of physicians' attitudes towards IMASIS revealed a lack of confidence globally. This was probably the consequence of two current features: a lack of complete information about IMASIS possibilities and problems faced when using the system. To deal with such factors, three types of measures have been planned. First, an effort is to be done to ensure that every physician is able to adequately use the current system and understands long-term benefits of the project. This task will be better accomplished by personal interaction between clinicians and a physician from the Informatics Department than through formal teaching of IMASIS. Secondly, a protocol for evaluating the HIS is being developed and will be systematically applied to detect both database errors and systemUs design pitfalls. Finally, the IMASIS project has to find a convenient point for starting, to offer short-term re PMID

  13. Osteoporosis guideline implementation in family medicine using electronic medical records

    PubMed Central

    Pritchard, Janet; Karampatos, Sarah; Ioannidis, George; Adachi, Jonathan; Thabane, Lehana; Nash, Lynn; Mehan, Upe; Kozak, Joseph; Feldman, Sid; Hirsch, Steve; Jovaisas, Algis V.; Cheung, Angela; Lohfeld, Lynne; Papaioannou, Alexandra

    2016-01-01

    Abstract Objective To identify family physicians’ learning needs related to osteoporosis care; determine family physicians’ preferred modes of learning; and identify barriers to using electronic medical records (EMRs) to implement osteoporosis guidelines in practice. Design Web-based survey. Setting Ontario. Participants Family physicians. Main outcome measures Quantitative and qualitative data about learning needs related to osteoporosis diagnosis and management; preferred mode of learning about guidelines; and barriers to using EMRs to implement guidelines. Results Of the 12 332 family physicians invited to participate in the survey, 8.5% and 7.0% provided partial or fully completed surveys, respectively. More than 80% of respondents agreed that the priority areas for education were as follows: selecting laboratory tests for secondary osteoporosis and interpreting the test results; interpreting bone mineral density results; determining appropriate circumstances for ordering anterior-posterior lumbar spine x-ray scans; and understanding duration, types, and adverse effects of pharmacotherapy. Qualitative analysis revealed that managing moderate-risk patients was a learning need. Continuing medical education was the preferred mode of learning. Approximately 80% of respondents agreed that the scarcity of EMR tools to aid in guideline implementation was a barrier to using guidelines, and 50% of respondents agreed that if EMR-embedded tools were available, time would limit their ability to use them. Conclusion This survey identified key diagnostic- and treatment-related topics in osteoporosis care that should be the focus of future continuing professional development for family physicians. Developers of EMR tools, physicians, and researchers aiming to implement guidelines to improve osteoporosis care should consider the potential barriers indicated in this study.

  14. A context-aware approach for progression tracking of medical concepts in electronic medical records.

    PubMed

    Chang, Nai-Wen; Dai, Hong-Jie; Jonnagaddala, Jitendra; Chen, Chih-Wei; Tsai, Richard Tzong-Han; Hsu, Wen-Lian

    2015-12-01

    Electronic medical records (EMRs) for diabetic patients contain information about heart disease risk factors such as high blood pressure, cholesterol levels, and smoking status. Discovering the described risk factors and tracking their progression over time may support medical personnel in making clinical decisions, as well as facilitate data modeling and biomedical research. Such highly patient-specific knowledge is essential to driving the advancement of evidence-based practice, and can also help improve personalized medicine and care. One general approach for tracking the progression of diseases and their risk factors described in EMRs is to first recognize all temporal expressions, and then assign each of them to the nearest target medical concept. However, this method may not always provide the correct associations. In light of this, this work introduces a context-aware approach to assign the time attributes of the recognized risk factors by reconstructing contexts that contain more reliable temporal expressions. The evaluation results on the i2b2 test set demonstrate the efficacy of the proposed approach, which achieved an F-score of 0.897. To boost the approach's ability to process unstructured clinical text and to allow for the reproduction of the demonstrated results, a set of developed .NET libraries used to develop the system is available at https://sites.google.com/site/hongjiedai/projects/nttmuclinicalnet. PMID:26432355

  15. Extracting medical information from narrative patient records: the case of medication-related information

    PubMed Central

    Grouin, Cyril; Zweigenbaum, Pierre

    2010-01-01

    Objective While essential for patient care, information related to medication is often written as free text in clinical records and, therefore, difficult to use in computerized systems. This paper describes an approach to automatically extract medication information from clinical records, which was developed to participate in the i2b2 2009 challenge, as well as different strategies to improve the extraction. Design Our approach relies on a semantic lexicon and extraction rules as a two-phase strategy: first, drug names are recognized and, then, the context of these names is explored to extract drug-related information (mode, dosage, etc) according to rules capturing the document structure and the syntax of each kind of information. Different configurations are tested to improve this baseline system along several dimensions, particularly drug name recognition—this step being a determining factor to extract drug-related information. Changes were tested at the level of the lexicons and of the extraction rules. Results The initial system participating in i2b2 achieved good results (global F-measure of 77%). Further testing of different configurations substantially improved the system (global F-measure of 81%), performing well for all types of information (eg, 84% for drug names and 88% for modes), except for durations and reasons, which remain problematic. Conclusion This study demonstrates that a simple rule-based system can achieve good performance on the medication extraction task. We also showed that controlled modifications (lexicon filtering and rule refinement) were the improvements that best raised the performance. PMID:20819863

  16. Cognitive analyses of a paper medical record and electronic medical record on the documentation of two nursing tasks: patient education and adherence assessment of insulin administration.

    PubMed Central

    Rinkus, Susan M.; Chitwood, Ainsley

    2002-01-01

    The incorporation of electronic medical records into busy physician clinics has been a major development in the healthcare industry over the past decade. Documentation of key nursing activities, especially when interacting with patients who have chronic diseases, is often lacking or missing from the paper medical record. A case study of a patient with diabetes mellitus was created. Well established methods for the assessment of usability in the areas of human-computer interaction and computer supported cooperative work were employed to compare the nursing documentation of two tasks in a commercially available electronic medical record (eRecord) and in a paper medical record. Overall, the eRecord was found to improve the timeliness and quality of nursing documentation. With certain tasks, the number of steps to accomplish the same task was higher, which may result in the perception by the end user that the tool is more complex and therefore difficult to use. Recommendations for the eRecord were made to expand the documentation of patient teaching and adherence assessment and to incorporate web technology for patient access to medical records and healthcare information. PMID:12463905

  17. Development and Use of Mark Sense Record Cards for Recording Medical Data on Pilots Subjected to Acceleration Stress

    NASA Technical Reports Server (NTRS)

    Smedal, Harald A.; Havill, C. Dewey

    1962-01-01

    A TIME-HONORED system of recording medical histories and the data obtained on physical and laboratory examination has been that of writing the information on record sheets that go into a folder for each patient. In order to have information which would be more readily retrieved, 'a program was initiated in 1952 by the U. S. Naval School of Aviation Medicine in connection with their "Care of the Flyer" study to place this information on machine record cards. In 1958, a machine record card method was developed for recording medical data in connection with the astronaut selection program. Machine record cards were also developed by the Aero Medical Laboratory, Wright-Patterson AFB, Ohio, and the Aviation Medical Acceleration Laboratory, Naval Air Development Center, Johnsville, Pennsylvania, for use in connection with a variety of tests including acceleration stress.1 Therefore, a variety of systems resulted in which data of a medical nature could easily be recalled. During the NASA, Ames Research Center centrifuge studies/'S the pilot subjects were interviewed after each centrifuge run, or series of runs, and subjective information was recorded in a log book by the usual history taking methods referred to above. After the methods Were reviewed, it' was recognized that a card system would be very useful in recording data from our pilots after they had been exposed to acceleration stress. Since the acceleration stress cards already developed did not meet our requirements, it was decided a different card was needed.

  18. Identifying patient smoking status from medical discharge records.

    PubMed

    Uzuner, Ozlem; Goldstein, Ira; Luo, Yuan; Kohane, Isaac

    2008-01-01

    The authors organized a Natural Language Processing (NLP) challenge on automatically determining the smoking status of patients from information found in their discharge records. This challenge was issued as a part of the i2b2 (Informatics for Integrating Biology to the Bedside) project, to survey, facilitate, and examine studies in medical language understanding for clinical narratives. This article describes the smoking challenge, details the data and the annotation process, explains the evaluation metrics, discusses the characteristics of the systems developed for the challenge, presents an analysis of the results of received system runs, draws conclusions about the state of the art, and identifies directions for future research. A total of 11 teams participated in the smoking challenge. Each team submitted up to three system runs, providing a total of 23 submissions. The submitted system runs were evaluated with microaveraged and macroaveraged precision, recall, and F-measure. The systems submitted to the smoking challenge represented a variety of machine learning and rule-based algorithms. Despite the differences in their approaches to smoking status identification, many of these systems provided good results. There were 12 system runs with microaveraged F-measures above 0.84. Analysis of the results highlighted the fact that discharge summaries express smoking status using a limited number of textual features (e.g., "smok", "tobac", "cigar", Social History, etc.). Many of the effective smoking status identifiers benefit from these features. PMID:17947624

  19. Improving the medical records department processes by lean management

    PubMed Central

    Ajami, Sima; Ketabi, Saeedeh; Sadeghian, Akram; Saghaeinnejad-Isfahani, Sakine

    2015-01-01

    Background: Lean management is a process improvement technique to identify waste actions and processes to eliminate them. The benefits of Lean for healthcare organizations are that first, the quality of the outcomes in terms of mistakes and errors improves. The second is that the amount of time taken through the whole process significantly improves. Aims: The purpose of this paper is to improve the Medical Records Department (MRD) processes at Ayatolah-Kashani Hospital in Isfahan, Iran by utilizing Lean management. Materials and Methods: This research was applied and an interventional study. The data have been collected by brainstorming, observation, interview, and workflow review. The study population included MRD staff and other expert staff within the hospital who were stakeholders and users of the MRD. Statistical Analysis Used: The MRD were initially taught the concepts of Lean management and then formed into the MRD Lean team. The team then identified and reviewed the current processes subsequently; they identified wastes and values, and proposed solutions. Results: The findings showed that the MRD units (Archive, Coding, Statistics, and Admission) had 17 current processes, 28 wastes, and 11 values were identified. In addition, they offered 27 comments for eliminating the wastes. Conclusion: The MRD is the critical department for the hospital information system and, therefore, the continuous improvement of its services and processes, through scientific methods such as Lean management, are essential. Originality/Value: The study represents one of the few attempts trying to eliminate wastes in the MRD. PMID:26097862

  20. A critical pathway for electronic medical record selection.

    PubMed Central

    Holbrook, A.; Keshavjee, K.; Langton, K.; Troyan, S.; Millar, S.; Olantunji, S.; Pray, M.; Tytus, R.; Ford, P. T.

    2001-01-01

    Electronic medical records (EMRs) are increasingly becoming a necessary tool in health care. Given their potential to influence every aspect of health care, there has been surprisingly little rigorous research applied to this important piece of emerging health technology. An initial phase of the COMPETE study, which is examining the impact of EMRs on efficiency, quality of care and privacy concerns, involved a rigorous "critical pathway" approach to EMR selection for the study. A multidisciplinary team with clinical, technical and research expertise led an 8-stage evaluation process with direct input from user physicians at each stage. An iterative sequence of review of EMR specifications and features, live product demonstrations, site visits, and negotiations with vendors led to a progressive narrowing of the field of eligible EMR systems. Final scoring was based on 3 main themes of clinical usability, data quality and support/vendor issues. We believe that a rigorous, multidisciplinary process such as this is required to maximize success of any EMR implementation project. PMID:11825192

  1. Electronic medical records: a practitioner's perspective on evaluation and implementation.

    PubMed

    Diamond, Edward; French, Kim; Gronkiewicz, Cynthia; Borkgren, Marilyn

    2010-09-01

    This article describes the initial and ongoing efforts of our pulmonary medicine practice to deploy an electronic medical records (EMR) system. Key factors in the vendor selection and implementation process included (1) identification and commitment to long-term goals for EMR; (2) dedicated resources, including both physician and nonphysician champions to lead the design and implementation teams; and (3) ample patience and time allotted to achieve the desired results: a fully functional system that enhances quality, improves operational efficiency, and reduces costs. An EMR scorecard including multiple system attributes was designed to facilitate vendor comparisons. Perseverance, patience, and compromise were necessary to overcome the challenge of changing the behavior of providers and support staff. We have accomplished improvements in workflow automation and reductions in staff hours, office supplies, file space, and transcription costs. Our system lacks pulmonary-specific templates and prompts for work flow and clinical decision making. We have directed internal resources and outsourced professional support to design these features as our practice strives to enhance our quality of care with pulmonary disease management that conforms to national guidelines. PMID:20822993

  2. Development of Mobile Platform Integrated with Existing Electronic Medical Records

    PubMed Central

    Kim, YoungAh; Kang, Simon; Kim, Kyungduk; Kim, Jun

    2014-01-01

    Objectives This paper describes a mobile Electronic Medical Record (EMR) platform designed to manage and utilize the existing EMR and mobile application with optimized resources. Methods We structured the mEMR to reuse services of retrieval and storage in mobile app environments that have already proven to have no problem working with EMRs. A new mobile architecture-based mobile solution was developed in four steps: the construction of a server and its architecture; screen layout and storyboard making; screen user interface design and development; and a pilot test and step-by-step deployment. This mobile architecture consists of two parts, the server-side area and the client-side area. In the server-side area, it performs the roles of service management for EMR and documents and for information exchange. Furthermore, it performs menu allocation depending on user permission and automatic clinical document architecture document conversion. Results Currently, Severance Hospital operates an iOS-compatible mobile solution based on this mobile architecture and provides stable service without additional resources, dealing with dynamic changes of EMR templates. Conclusions The proposed mobile solution should go hand in hand with the existing EMR system, and it can be a cost-effective solution if a quality EMR system is operated steadily with this solution. Thus, we expect this example to be shared with hospitals that currently plan to deploy mobile solutions. PMID:25152837

  3. Anonymization of DICOM electronic medical records for radiation therapy.

    PubMed

    Newhauser, Wayne; Jones, Timothy; Swerdloff, Stuart; Newhauser, Warren; Cilia, Mark; Carver, Robert; Halloran, Andy; Zhang, Rui

    2014-10-01

    Electronic medical records (EMR) and treatment plans are used in research on patient outcomes and radiation effects. In many situations researchers must remove protected health information (PHI) from EMRs. The literature contains several studies describing the anonymization of generic Digital Imaging and Communication in Medicine (DICOM) files and DICOM image sets but no publications were found that discuss the anonymization of DICOM radiation therapy plans, a key component of an EMR in a cancer clinic. In addition to this we were unable to find a commercial software tool that met the minimum requirements for anonymization and preservation of data integrity for radiation therapy research. The purpose of this study was to develop a prototype software code to meet the requirements for the anonymization of radiation therapy treatment plans and to develop a way to validate that code and demonstrate that it properly anonymized treatment plans and preserved data integrity. We extended an open-source code to process all relevant PHI and to allow for the automatic anonymization of multiple EMRs. The prototype code successfully anonymized multiple treatment plans in less than 1min/patient. We also tested commercial optical character recognition (OCR) algorithms for the detection of burned-in text on the images, but they were unable to reliably recognize text. In addition, we developed and tested an image filtering algorithm that allowed us to isolate and redact alpha-numeric text from a test radiograph. Validation tests verified that PHI was anonymized and data integrity, such as the relationship between DICOM unique identifiers (UID) was preserved. PMID:25147130

  4. Consumers' Perceptions of Patient-Accessible Electronic Medical Records

    PubMed Central

    Vaughon, Wendy L; Czaja, Sara J; Levy, Joslyn; Rockoff, Maxine L

    2013-01-01

    Background Electronic health information (eHealth) tools for patients, including patient-accessible electronic medical records (patient portals), are proliferating in health care delivery systems nationally. However, there has been very limited study of the perceived utility and functionality of portals, as well as limited assessment of these systems by vulnerable (low education level, racial/ethnic minority) consumers. Objective The objective of the study was to identify vulnerable consumers’ response to patient portals, their perceived utility and value, as well as their reactions to specific portal functions. Methods This qualitative study used 4 focus groups with 28 low education level, English-speaking consumers in June and July 2010, in New York City. Results Participants included 10 males and 18 females, ranging in age from 21-63 years; 19 non-Hispanic black, 7 Hispanic, 1 non-Hispanic White and 1 Other. None of the participants had higher than a high school level education, and 13 had less than a high school education. All participants had experience with computers and 26 used the Internet. Major themes were enhanced consumer engagement/patient empowerment, extending the doctor’s visit/enhancing communication with health care providers, literacy and health literacy factors, improved prevention and health maintenance, and privacy and security concerns. Consumers were also asked to comment on a number of key portal features. Consumers were most positive about features that increased convenience, such as making appointments and refilling prescriptions. Consumers raised concerns about a number of potential barriers to usage, such as complex language, complex visual layouts, and poor usability features. Conclusions Most consumers were enthusiastic about patient portals and perceived that they had great utility and value. Study findings suggest that for patient portals to be effective for all consumers, portals must be designed to be easy to read, visually

  5. Anonymization of DICOM Electronic Medical Records for Radiation Therapy

    PubMed Central

    Newhauser, Wayne; Jones, Timothy; Swerdloff, Stuart; Newhauser, Warren; Cilia, Mark; Carver, Robert; Halloran, Andy; Zhang, Rui

    2014-01-01

    Electronic medical records (EMR) and treatment plans are used in research on patient outcomes and radiation effects. In many situations researchers must remove protected health information (PHI) from EMRs. The literature contains several studies describing the anonymization of generic Digital Imaging and Communication in Medicine (DICOM) files and DICOM image sets but no publications were found that discuss the anonymization of DICOM radiation therapy plans, a key component of an EMR in a cancer clinic. In addition to this we were unable to find a commercial software tool that met the minimum requirements for anonymization and preservation of data integrity for radiation therapy research. The purpose of this study was to develop a prototype software code to meet the requirements for the anonymization of radiation therapy treatment plans and to develop a way to validate that code and demonstrate that it properly anonymized treatment plans and preserved data integrity. We extended an open-source code to process all relevant PHI and to allow for the automatic anonymization of multiple EMRs. The prototype code successfully anonymized multiple treatment plans in less than 1 minute per patient. We also tested commercial optical character recognition (OCR) algorithms for the detection of burned-in text on the images, but they were unable to reliably recognize text. In addition, we developed and tested an image filtering algorithm that allowed us to isolate and redact alpha-numeric text from a test radiograph. Validation tests verified that PHI was anonymized and data integrity, such as the relationship between DICOM unique identifiers (UID) was preserved. PMID:25147130

  6. Congruence of Self-Reported Medications with Pharmacy Prescription Records in Low-Income Older Adults

    ERIC Educational Resources Information Center

    Caskie, Grace I. L.; Willis, Sherry L.

    2004-01-01

    Purpose: This study examined the congruence of self-reported medications with computerized pharmacy records. Design and Methods: Pharmacy records and self-reported medications were obtained for 294 members of a state pharmaceutical assistance program who also participated in ACTIVE, a clinical trial on cognitive training in nondemented elderly…

  7. 29 CFR 1926.33 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 8 2010-07-01 2010-07-01 false Access to employee exposure and medical records. 1926.33 Section 1926.33 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Health Provisions § 1926.33 Access to employee exposure and medical records. Note: The...

  8. 29 CFR 1915.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 29 Labor 7 2013-07-01 2013-07-01 false Access to employee exposure and medical records. 1915.1020 Section 1915.1020 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Toxic and Hazardous Substances § 1915.1020 Access to employee exposure and medical records. Note:...

  9. Urban Alabama Physicians and the Electronic Medical Record: A Qualitative Study

    ERIC Educational Resources Information Center

    Tiggle, Michele

    2012-01-01

    The electronic medical record (EMR) is an information technology tool supporting the examination, treatment, and care of a patient. The EMR allows physicians to view a patient's record showing current medications, a history of visits from health care providers with notes from those visits, a problem list, a functional status assessment, a…

  10. 29 CFR 1926.33 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 29 Labor 8 2012-07-01 2012-07-01 false Access to employee exposure and medical records. 1926.33 Section 1926.33 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Health Provisions § 1926.33 Access to employee exposure and medical records. Note: The...

  11. 77 FR 64387 - Agency Information Collection (Request for and Authorization To Release Medical Records or Health...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-10-19

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF VETERANS AFFAIRS Agency Information Collection (Request for and Authorization To Release Medical Records or Health... Release Medical Records or Health Information, VA Form 10-5345. b. Individual's Request for a Copy...

  12. 29 CFR 2400.7 - Special procedures for requesting medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 29 Labor 9 2014-07-01 2014-07-01 false Special procedures for requesting medical records. 2400.7 Section 2400.7 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH REVIEW COMMISSION REGULATIONS IMPLEMENTING THE PRIVACY ACT § 2400.7 Special procedures for requesting medical records. (a) Upon an individual's request...

  13. 29 CFR 1926.33 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 29 Labor 8 2013-07-01 2013-07-01 false Access to employee exposure and medical records. 1926.33 Section 1926.33 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Health Provisions § 1926.33 Access to employee exposure and medical records. Note: The...

  14. 29 CFR 1915.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 7 2011-07-01 2011-07-01 false Access to employee exposure and medical records. 1915.1020 Section 1915.1020 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Toxic and Hazardous Substances § 1915.1020 Access to employee exposure and medical records. Note:...

  15. 29 CFR 1926.33 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 29 Labor 8 2011-07-01 2011-07-01 false Access to employee exposure and medical records. 1926.33 Section 1926.33 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Health Provisions § 1926.33 Access to employee exposure and medical records. Note: The...

  16. 29 CFR 1915.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 29 Labor 7 2012-07-01 2012-07-01 false Access to employee exposure and medical records. 1915.1020 Section 1915.1020 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Toxic and Hazardous Substances § 1915.1020 Access to employee exposure and medical records. Note:...

  17. Improving the Quality of Nursing Home Care and Medical-Record Accuracy with Direct Observational Technologies

    ERIC Educational Resources Information Center

    Schnelle, John F.; Osterweil, Dan; Simmons, Sandra F.

    2005-01-01

    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…

  18. 29 CFR 1926.33 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 29 Labor 8 2014-07-01 2014-07-01 false Access to employee exposure and medical records. 1926.33 Section 1926.33 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH... Health Provisions § 1926.33 Access to employee exposure and medical records. Note: The...

  19. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 45 Public Welfare 1 2014-10-01 2014-10-01 false Special procedures for notification of or access to medical records. 5b.6 Section 5b.6 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION PRIVACY ACT REGULATIONS § 5b.6 Special procedures for notification of or access to medical records. (a) General. An individual...

  20. Roles, Functions, Training, and Proficiency Tests for Medical Record Personnel: A Guide to Curriculum Management.

    ERIC Educational Resources Information Center

    Clark, Fredric A.

    The curriculum management guide serves as an aid to medical record teachers and other medical record educators. It is designed to provide them with a useful tool to improve student performances by improved administration and management of programs. The guide documents one possible systematic approach to professional and vocational curriculum…

  1. Linking human anatomy to knowledge bases: a visual front end for electronic medical records.

    PubMed

    Dickson, Stewart; Pouchard, Line; Ward, Richard; Atkins, Gary; Cole, Martin; Lorensen, Bill; Ade, Alexander

    2005-01-01

    A new concept of a visual electronic medical record is presented based on developments ongoing in the Defense Advanced Research Projects Agency Virtual Soldier Project. This new concept is based on the holographic medical electronic representation (Holomer) and on data formats being developed to support this. The Holomer is being developed in two different visualization environments, one of which is suitable for prototyping the visual electronic medical record. The advantages of a visual approach as a front end for electronic medical records are discussed and specific implementations are presented. PMID:15718802

  2. The development of medical record services in Hong Kong public hospitals.

    PubMed

    Fung, V

    1994-12-01

    Medical record service in Hong Kong public hospitals have been developing at different levels. Since 1992, various improvements in medical record services have been carried out in public hospitals, e.g. professional management, record storage, organized medical records, computerization, completion of discharge summaries, and the introduction of a more precise coding system. The aim of the reform is to provide timely, accurate, organized and meaningful clinical information for end-users. Evolving from this reform, work has been started on developing Patient Related Groups and Specialty Clinical Information Systems. PMID:10142476

  3. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  4. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  5. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  6. 42 CFR 102.50 - Medical records necessary to establish that a covered injury was sustained.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... date of the smallpox vaccination or exposure to vaccinia; and (2) All inpatient hospital medical... of the smallpox vaccination or exposure to vaccinia. (b) A requester may submit additional medical... sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or...

  7. Feasibility Study for Establishing Three Medical Record Related Programs. Research Report Series Volume XIV, No. 12.

    ERIC Educational Resources Information Center

    William Rainey Harper Coll., Palatine, IL. Office of Planning and Research.

    In November 1985, a survey was conducted at William Rainey Harper College (WRHC), in Illinois, to test the feasibility of establishing programs for medical record technicians, medical coders, and utilization analysts. The survey instrument was mailed to 1,232 hospitals, medical care facilities, nursing homes, physicians' and dentists' offices, and…

  8. DRUG-DRUG INTERACTION PROFILES OF MEDICATION REGIMENS EXTRACTED FROM A DE-IDENTIFIED ELECTRONIC MEDICAL RECORDS SYSTEM.

    PubMed

    Butkiewicz, Mariusz; Restrepo, Nicole A; Haines, Jonathan L; Crawford, Dana C

    2016-01-01

    With age, the number of prescribed medications increases and subsequently raises the risk for adverse drug-drug interactions. These adverse effects lower quality of life and increase health care costs. Quantifying the potential burden of adverse effects before prescribing medications can be a valuable contribution to health care. This study evaluated medication lists extracted from a subset of the Vanderbilt de-identified electronic medical record system. Reported drugs were cross-referenced with the Kyoto Encyclopedia of Genes and Genomes DRUG database to identify known drug-drug interactions. On average, a medication regimen contained 6.58 medications and 2.68 drug-drug interactions. Here, we quantify the burden of potential adverse events from drug-drug interactions through drug-drug interaction profiles and include a number of alternative medications as provided by the Anatomical Therapeutic Chemical Classification System. PMID:27570646

  9. 42 CFR 110.50 - Medical records necessary for the Secretary to determine whether a covered injury was sustained.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 1 2013-10-01 2013-10-01 false Medical records necessary for the Secretary to... Required for the Secretary To Determine Eligibility § 110.50 Medical records necessary for the Secretary to... submit to the Program the following medical records, as defined in § 110.3(p): (1) All medical...

  10. 42 CFR 110.50 - Medical records necessary for the Secretary to determine whether a covered injury was sustained.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 1 2011-10-01 2011-10-01 false Medical records necessary for the Secretary to... Required for the Secretary To Determine Eligibility § 110.50 Medical records necessary for the Secretary to... submit to the Program the following medical records, as defined in § 110.3(p): (1) All medical...

  11. 42 CFR 110.50 - Medical records necessary for the Secretary to determine whether a covered injury was sustained.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 1 2012-10-01 2012-10-01 false Medical records necessary for the Secretary to... Required for the Secretary To Determine Eligibility § 110.50 Medical records necessary for the Secretary to... submit to the Program the following medical records, as defined in § 110.3(p): (1) All medical...

  12. 20 CFR 30.113 - What are the requirements for written medical documentation, contemporaneous records, and other...

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... the medical records containing a diagnosis and date of diagnosis of a covered medical condition no... 20 Employees' Benefits 1 2014-04-01 2012-04-01 true What are the requirements for written medical... written medical documentation, contemporaneous records, and other records or documents? (a) All...

  13. 20 CFR 30.113 - What are the requirements for written medical documentation, contemporaneous records, and other...

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... the medical records containing a diagnosis and date of diagnosis of a covered medical condition no... 20 Employees' Benefits 1 2012-04-01 2012-04-01 false What are the requirements for written medical... written medical documentation, contemporaneous records, and other records or documents? (a) All...

  14. 42 CFR 110.50 - Medical records necessary for the Secretary to determine whether a covered injury was sustained.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 1 2014-10-01 2014-10-01 false Medical records necessary for the Secretary to... Required for the Secretary To Determine Eligibility § 110.50 Medical records necessary for the Secretary to... submit to the Program the following medical records, as defined in § 110.3(p): (1) All medical...

  15. The sensitivity of medical diagnostic decision-support knowledge bases in delineating appropriate terms to document in the medical record.

    PubMed Central

    Feldman, M. J.; Barnett, G. O.; Morgan, M. M.

    1991-01-01

    A pertinent, legible and complete medical record facilitates good patient care. The recording of the symptoms, signs and lab findings which are relevant to a patient's condition contributes importantly to the medical record. The consideration and documentation of other disease states known to be related to the patient's primary illness provide further enhancement. We propose that developing sets of disease-specific core elements which a physician may want to document in the medical record can have many benefits. We hypothesize that for a given disease, terms with high importance (TI) and frequency (TF) in the DX-plain, QMR and Iliad knowledge bases (KBs) are terms which are used commonly in the medical record, and may be, in fact, terms which physicians would find useful to document. A study was undertaken to validate ten such sets of disease-specific core elements. For each of ten prevalent diseases, high TI and TF terms from the three KBs mentioned were pooled to derive the set of core elements. For each disease, all patient records (range 385 to 16,972) from a computerized ambulatory medical record database were searched to document the actual use by physicians of each of these core elements. A significant percentage (range 50 to 86%) of each set of core elements was confirmed as being used by the physicians. In addition, all medical concepts from a selection of full text records were identified, and an average of 65% of the concepts were found to be core elements.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1807600

  16. An integrated nursing-pharmacy approach to a computerized medication dispensing/administration system.

    PubMed

    Cook, A A

    1985-05-01

    This paper describes the collaborative efforts of the nursing and pharmacy departments to develop a nurse-generated/pharmacist-verified computerized medication administration record (MAR). The objectives were to improve accuracy in dispensing and administering medications and a avoid duplicate labor efforts created by separate records to dispense and to administer the medications. These efforts provided the nurses with an accurate record to administer the medication and the physicians with an informative record with which to review their patient's drug therapy. PMID:10271106

  17. Medical records. Enhancing privacy, preserving the common good.

    PubMed

    Etzioni, A

    1999-01-01

    Personal medical information is now bought and sold on the open market. Companies use it to make hiring and firing decisions and to identify customers for new products. The justification for providing such access to medical information is that doing so benefits the public by securing public safety, controlling costs, and supporting medical research. And individuals have supposedly consented to it. But we can achieve the common goods while better protecting privacy by making institutional changes in the way information is maintained and protected. PMID:10321335

  18. Physician Interaction with Electronic Medical Records: A Qualitative Study

    ERIC Educational Resources Information Center

    Noteboom, Cherie Bakker

    2010-01-01

    The integration of EHR (Electronic Health Records) in IT infrastructures supporting organizations enable improved access to and recording of patient data, enhanced ability to make better and more-timely decisions, and improved quality and reduced errors. Despite these benefits, there are mixed results as to the use of EHR. The literature suggests…

  19. Self-Care Communication during Medical Encounters: Implications for Future Electronic Medical Records

    PubMed Central

    Arar, Nedal H; Wang, Chen-Pin; Pugh, Jacqueline A

    2006-01-01

    Objective The growing importance of electronic medical records (EMRs) to healthcare systems is evident, yet the debate concerning their impact on patient-provider communication during encounters remains unresolved. For this study, we hypothesize that providers' use of the EMR will improve patientprovider communication concerning self-care during the medical encounter. Design Cross-sectional, observational study. Setting A primary-care outpatient clinic of the South Texas Veterans Health Care System in San Antonio, TX, USA. Methods A convenience sample of 50 patient/physician encounters was videotaped, transcribed verbatim, and analyzed to determine the time that the physician spent using the EMR and self-care topics discussed. Self-care topics included medication use, recognition of disease symptoms, diet, exercise, management of physical and emotional distress, self-monitoring activities, cigarette smoking, alcohol consumption, and family support/community resources. Two observers independently coded for the kind of self-care topics (kappa = 0.91) using the Atlas.ti software package. Results Encounters averaged 22.6 minutes (range: 5–47, SD = 8.9). We identified two encounter types based on EMR usage: low use (n = 13), with EMR use of two minutes or less, and moderate to high EMR use (n = 37), with EMR use of five minutes or more. Average time for encounters was 25 minutes for moderate to high EMR use encounters and 16 minutes for low EMR use encounters (t test, p < 0.001). Issues pertaining to facets of self-care management were discussed in every physician-patient interaction (100 percent). The most frequently discussed self-care topics were medication use (100 percent), physical distress (76 percent), and disease symptoms (76 percent). Self-monitoring activities, exercise, and diet were discussed in 62 percent, 60 percent, and 46 percent of the 50 encounters respectively. Emotional distress (26 percent), smoking (30 percent), family support

  20. A Software System to Collect Expert Relevance Ratings of Medical Record Items for Specific Clinical Tasks

    PubMed Central

    Krishnaraj, Arun; Alkasab, Tarik K

    2014-01-01

    Development of task-specific electronic medical record (EMR) searches and user interfaces has the potential to improve the efficiency and safety of health care while curbing rising costs. The development of such tools must be data-driven and guided by a strong understanding of practitioner information requirements with respect to specific clinical tasks or scenarios. To acquire this important data, this paper describes a model by which expert practitioners are leveraged to identify which components of the medical record are most relevant to a specific clinical task. We also describe the computer system that was created to efficiently implement this model of data gathering. The system extracts medical record data from the EMR of patients matching a given clinical scenario, de-identifies the data, breaks the data up into separate medical record items (eg, radiology reports, operative notes, laboratory results, etc), presents each individual medical record item to experts under the hypothetical of the given clinical scenario, and records the experts’ ratings regarding the relevance of each medical record item to that specific clinical scenario or task. After an iterative process of data collection, these expert relevance ratings can then be pooled and used to design point-of-care EMR searches and user interfaces tailored to the task-specific needs of practitioners. PMID:25600925

  1. Medical Emergency Exceptions in State Abortion Statutes: The Statistical Record.

    PubMed

    Linton, Paul Benjamin

    2016-01-01

    This article attempts to determine, first, whether emergency exceptions in statutes regulating abortion have been abused and, second, whether the standard used in such an exception--subjective or objective--makes a difference in the reported incidence of such emergencies. A review of the statistical data supports two conclusions. First, physicians who perform abortions and have complied with state reporting requirements have not relied upon the medical emergency exceptions in state abortion statutes to evade the requirements of those statutes. Second, the use of an objective standard for evaluating medical emergencies ("reasonable medical judgment") has not been associated with fewer reported emergencies (per number of abortions performed) than the use of a subjective standard ("good faith clinical judgment"). Both of these conclusions may be relevant in drafting other abortion statutes including prohibitions (e.g., post-viability abortions). PMID:27323547

  2. TECHNIQUES OF TAPE PREPARATION AND DUPLICATION, WITH SUGGESTIONS FOR A LANGUAGE LABORATORY.

    ERIC Educational Resources Information Center

    Kansas State Dept. of Public Instruction, Topeka.

    PART ONE OF THIS BULLETIN PROVIDES HELP IN THE TWO CRITICAL AREAS OF MASTER TAPE PREPARATION AND DUPLICATION. SUPPLEMENTED BY NUMEROUS PHOTOGRAPHS AND DIAGRAMS OF EQUIPMENT AND DUPLICATION TECHNIQUES, THE BULLETIN DESCRIBES MASTER PROGRAM DUPLICATION USING LANGUAGE LABORATORY EQUIPMENT, A PROFESSIONAL MASS DUPLICATOR, A TAPE RECORDER, A RECORD…

  3. Does the HIPAA Privacy Rule Allow Parents the Right to See Their Children's Medical Records?

    MedlinePlus

    ... Does the HIPAA Privacy Rule allow parents the right to see their children’s medical records? Answer: Yes, ... your contact information below. Email Office for Civil Rights Headquarters U.S. Department of Health & Human Services 200 ...

  4. Method for developing national quality indicators based on manual data extraction from medical records.

    PubMed

    Couralet, Melanie; Leleu, Henri; Capuano, Frederic; Marcotte, Leah; Nitenberg, Gérard; Sicotte, Claude; Minvielle, Etienne

    2013-02-01

    Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs. We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries. PMID:23015098

  5. Electronic Medical Record and Quality Ratings of Long Term Care Facilities Long-Term Care Facility Characteristics and Reasons and Barriers for Adoption of Electronic Medical Record

    ERIC Educational Resources Information Center

    Daniels, Cheryl Andrea

    2013-01-01

    With the growing elderly population, compounded by the retirement of the babyboomers, the need for long-term care (LTC) facilities is expected to grow. An area of great concern for those that are seeking a home for their family member is the quality of care provided by the nursing home to the residents. Electronic medical records (EMR) are often…

  6. Documentation of Medical Records in Hospitals of Mazandaran University of Medical Sciences in 2014: a Quantitative Study

    PubMed Central

    Saravi, Benyamin Mohseni; Asgari, Zolaykha; Siamian, Hasan; Farahabadi, Ebrahim Bagherian; Gorji, Alimorad Heidari; Motamed, Nima; Fallahkharyeki, Mohammad; Mohammadi, Ramin

    2016-01-01

    Introduction: Documentation of patient care in medical record formats is always emphasized. These documents are used as a means to go on treating the patients, staff in their own defense, assessment, care, any legal proceedings and medical science education. Therefore, in this study, each of the data elements available in patients’ records are important and filling them indicates the importance put by the documenting teams, so it has been dealt with the documentation the patient records in the hospitals of Mazandaran province. Method: This cross-sectional study aimed to review medical records in 16 hospitals of Mazandaran University of Medical Sciences (MazUMS). In order to collection data, a check list was prepared based on the data elements including four forms of the admission, summary, patients’ medical history and progress note. The data recording was defined as “Yes” with the value of 1, lack of recording was defined as “No” with the value of 2, and “Not applied” with the value of 0 for the cases in which the mentioned variable medical records are not applied. Results: The overall evaluation of the documentation was considered as 95-100% equal to “good”, 75-94% equal to “average” and below -75% equal to “poor”. Using the stratified random sample volume formula, 381 cases were reviewed. The data were analyzed by the SPSS version 19 and descriptive statistics. Results: The results showed that %62 of registration and all the four forms were in the “poor” category. There was no big difference in average registration among the hospitals. Among the educational groups Gynecology and Infectious were equal and had the highest average of documentation of %68. In the data categories, the highest documentation average belonged to the verification, %91. Conclusion: According to the overall assessment in which the rate of documentation was in the category “week”, we should make much more efforts to reach better conditions. Even if a data

  7. 5 CFR 875.103 - Do I need to authorize release of my medical records when I file a claim?

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... medical records when I file a claim? 875.103 Section 875.103 Administrative Personnel OFFICE OF PERSONNEL... Administration and General Provisions § 875.103 Do I need to authorize release of my medical records when I file... you to release your medical records....

  8. 5 CFR 875.103 - Do I need to authorize release of my medical records when I file a claim?

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... medical records when I file a claim? 875.103 Section 875.103 Administrative Personnel OFFICE OF PERSONNEL... Administration and General Provisions § 875.103 Do I need to authorize release of my medical records when I file... you to release your medical records....

  9. 5 CFR 875.103 - Do I need to authorize release of my medical records when I file a claim?

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... medical records when I file a claim? 875.103 Section 875.103 Administrative Personnel OFFICE OF PERSONNEL... Administration and General Provisions § 875.103 Do I need to authorize release of my medical records when I file... you to release your medical records....

  10. 5 CFR 875.103 - Do I need to authorize release of my medical records when I file a claim?

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... medical records when I file a claim? 875.103 Section 875.103 Administrative Personnel OFFICE OF PERSONNEL... Administration and General Provisions § 875.103 Do I need to authorize release of my medical records when I file... you to release your medical records....

  11. 5 CFR 875.103 - Do I need to authorize release of my medical records when I file a claim?

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... medical records when I file a claim? 875.103 Section 875.103 Administrative Personnel OFFICE OF PERSONNEL... Administration and General Provisions § 875.103 Do I need to authorize release of my medical records when I file... you to release your medical records....

  12. Research strategies that result in optimal data collection from the patient medical record.

    PubMed

    Gregory, Katherine E; Radovinsky, Lucy

    2012-05-01

    Data obtained from the patient medical record are often a component of clinical research led by nurse investigators. The rigor of the data collection methods correlates to the reliability of the data and, ultimately, the analytical outcome of the study. Research strategies for reliable data collection from the patient medical record include the development of a precise data collection tool, the use of a coding manual, and ongoing communication with research staff. PMID:20974093

  13. Survey of electronic veterinary medical record adoption and use by independent small animal veterinary medical practices in Massachusetts

    PubMed Central

    Krone, Lauren M.; Brown, Catherine M.; Lindenmayer, Joann M.

    2016-01-01

    Objective To estimate the proportion of independent small animal veterinary medical practices in Massachusetts that use electronic veterinary medical records (EVMRs), determine the purposes for which EVMRs are used, and identify perceived barriers to their use. Design Survey. Sample 100 veterinarians. Procedures 213 of 517 independent small animal veterinary practices operating in Massachusetts were randomly chosen for study recruitment. One veterinarian at each practice was invited by telephone to answer a hardcopy survey regarding practice demographics, medical records type (electronic, paper, or both), purposes of EVMR use, and perceived barriers to adoption. Surveys were mailed to the first 100 veterinarians who agreed to participate. Practices were categorized by record type and size (large [≥ 5 veterinarians], medium [3 to 4 veterinarians], or small [1 to 2 veterinarians]). Results 84 surveys were returned; overall response was 84 of 213 (39.4%). The EVMRs were used alone or together with paper records in 66 of 82 (80.5%) practices. Large and medium-sized practices were significantly more likely to use EVMRs combined with paper records than were small practices. The EVMRs were most commonly used for ensuring billing, automating reminders, providing cost estimates, scheduling, recording medical and surgical information, and tracking patient health. Least common uses were identifying emerging infectious diseases, research, and insurance. Eleven veterinarians in paper record–only practices indicated reluctance to change, anticipated technological problems, time constraints, and cost were barriers to EVMR use. Conclusions and Clinical Relevance Results indicated EVMRs were underutilized as a tool for tracking and improving population health and identifying emerging infectious diseases. Efforts to facilitate adoption of EVMRs for these purposes should be strengthened by the veterinary medical, human health, and public health professions. PMID:25029312

  14. The PEN & PAD medical record model: development of a nursing record for hospital-based care of the elderly.

    PubMed

    Heathfield, H A; Hardiker, N; Kirby, J; Tallis, R; Gonsalkarale, M

    1994-12-01

    The PEN & PAD Medical Record model describes a framework for an information model, designed to meet the requirements of an electronic medical record. This model has been successfully tested in a computer-based record system for General Practitioners as part of the PEN & PAD (GP) Project. Experiences of using the model for developing computer-based nursing records are reported. Results show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient's care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work had highlighted the need for nurses to clarify and make explicit their uses of information, and also provided them with some tools to assist in this task. PMID:7869943

  15. ClinicalCodes: An Online Clinical Codes Repository to Improve the Validity and Reproducibility of Research Using Electronic Medical Records

    PubMed Central

    Springate, David A.; Kontopantelis, Evangelos; Ashcroft, Darren M.; Olier, Ivan; Parisi, Rosa; Chamapiwa, Edmore; Reeves, David

    2014-01-01

    Lists of clinical codes are the foundation for research undertaken using electronic medical records (EMRs). If clinical code lists are not available, reviewers are unable to determine the validity of research, full study replication is impossible, researchers are unable to make effective comparisons between studies, and the construction of new code lists is subject to much duplication of effort. Despite this, the publication of clinical codes is rarely if ever a requirement for obtaining grants, validating protocols, or publishing research. In a representative sample of 450 EMR primary research articles indexed on PubMed, we found that only 19 (5.1%) were accompanied by a full set of published clinical codes and 32 (8.6%) stated that code lists were available on request. To help address these problems, we have built an online repository where researchers using EMRs can upload and download lists of clinical codes. The repository will enable clinical researchers to better validate EMR studies, build on previous code lists and compare disease definitions across studies. It will also assist health informaticians in replicating database studies, tracking changes in disease definitions or clinical coding practice through time and sharing clinical code information across platforms and data sources as research objects. PMID:24941260

  16. Organizational Learning and Large-Scale Change: Adoption of Electronic Medical Records

    ERIC Educational Resources Information Center

    Chavis, Virginia D.

    2010-01-01

    Despite implementation of electronic medical record (EMR) systems in the United States and other countries, there is no organizational development model that addresses medical professionals' attitudes toward technology adoption in a learning organization. The purpose of this study was to assess whether a model would change those attitudes toward…

  17. Caudal duplication syndrome.

    PubMed

    Ramzan, Muhammad; Ahmed, Shoaib; Ali, Salman

    2014-01-01

    Complete duplication of genitourinary system, colon and vertebral column is a very rare and complex congenital condition termed as "caudal duplication syndrome" with variable presentations. This term is often quoted as a type of incomplete separation of mono-ovular twins or conjoined twinning. It is associated with other congenital malformations of the genitourinary, gastrointestinal and other organ systems. The hereby reported case, a 3-month-old male infant had presented with the classical form of the disease i.e., duplication of the gastrointestinal, genitourinary system and vertebral column with anterior abdominal wall hernia and a large lipomeningocele. PMID:24411548

  18. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Condition of participation: Special medical record... PARTICIPATION FOR HOSPITALS Requirements for Specialty Hospitals § 482.61 Condition of participation: Special... stated by the patient and/or others significantly involved. (4) The social service records,...

  19. Surgeons' perspective of a newly initiated electronic medical record

    PubMed Central

    Harmon, Laura; Papaconstantinou, Harry T.

    2016-01-01

    The American Recovery and Reinvestment Act mandates “meaningful use” of an electronic health record (EHR) to receive current financial incentives and to avoid future financial penalties. Surgeons' ongoing adoption of an EHR nationally will be influenced by the early experiences of institutions that have made the transition from paper to electronic records. We conducted a survey to query surgeons at our institution regarding their perception of the EHR 3 months after institutional implementation. A total of 59 surveys were obtained from 24 senior staff and 35 residents. Results showed that surgeons believed the EHR was more effective as a billing tool than as a form of clinical documentation and believed the billing was more complete and accurate with the EHR. Surgeons also expressed concern that the EHR would negatively impact patient satisfaction, but in spite of this, they indicated that their personal quality of life was not negatively impacted. PMID:26722158

  20. Recording wounds: Polaroid's new medically-designed cameras.

    PubMed

    Clarke, G

    2000-11-01

    Wound management is an important and increasingly complex area of nursing practice. Community nurses, in particular, spend a considerable amount of time assessing, evaluating and managing chronic, non-healing wounds. The rapid rise in the number of wound care products, combined with the emphasis on clinical governance and risk management, and increases in litigation have meant that accurate documentation and record keeping have become an essential part of care (UKCC, 1992, 1998). A standardized approach to assessment, classification, measurement and evaluation should be adopted to maximize optimal patient outcomes. There are a number of techniques for measuring wounds, ranging from manual measurement using tracing to computer-based imaging. Photography is a simple and quick form of documentation, which provides an accurate and objective record of the wound. This article highlights the benefits of using the new Polaroid Macro 5 SLR camera in wound documentation. PMID:12066058

  1. Patient experiences with electronic medical records: Lessons learned

    PubMed Central

    Rose, Dale; Richter, Louiseann T; Kapustin, Jane

    2014-01-01

    Purpose To describe the lived experience of patients communicating with their nurse practitioners and physicians while using paper health records (PHRs) and electronic health records (EHRs) in the examination rooms. The significance of the study lies in the salience of communication between the patient and provider in promoting optimal clinical outcomes and the highest level of patient satisfaction. Data sources The study used a qualitative, phenomenological design. Audio-taped focus group interviews were conducted with 21 patients from a diabetes clinic in Baltimore, Maryland. Patients had visits with the provider before and after implementation of EHRs in the clinic. Conclusions The four themes that emerged from the three focus groups included communication issues, patient preferences for electronic records, safety and security concerns, and transition problems with implementation of EHRs. Implications for practice Potential benefits for nurse practitioners implementing the recommendations in this study include enhanced communication between patients and providers while using EHRs, increased patient satisfaction, higher levels of nurse practitioner and physician satisfaction, and avoidance of communication issues during implementation of EHR systems. PMID:25234112

  2. The urban underserved: Attitudes toward gaining full access to electronic medical records

    PubMed Central

    Dhanireddy, Shireesha; Walker, Jan; Reisch, Lisa; Oster, Natalia; Delbanco, Thomas; Elmore, Joann

    2012-01-01

    Background As the use of electronic medical records (EMRs) spreads, health care organizations are increasingly offering patients online access to their medical records. Studies evaluating patient attitudes toward viewing elements of their records through secure, electronic patient portals have generally not included medically underserved patients or those with HIV/AIDS. The goal of this study was to gain insight into such patients’ attitudes toward online access to their medical records, including their doctors’ visit notes. Methods Qualitative study of four focus groups with adult patients in general adult medicine and HIV clinics at a large county hospital. Transcripts were analyzed for themes using an immersion/crystallization approach. Results Patients’ baseline understanding of the health record was limited. Perceived benefits of online access were improved patient understanding of health and disease, convenience, empowerment, and a stronger relationship with their provider. Concerns included threats to privacy, worries about being unable to understand their record, fear that the computer would replace direct provider contact, and hesitancy about potential demands on a provider’s time. Patients also recommended providing online visit reminders, links to credible health information, and assistance for paying bills. Conclusion Despite their initial lack of knowledge of the health record, focus group participants were overwhelmingly positive about the prospect of online access to medical records. However, they worried about potential loss of privacy and interference with the patient-provider relationship. As EMRs increasingly offer patients open access to their medical records, vulnerable patient groups will likely join others in desiring and adopting such change, but may need targeted support during times of transition. PMID:22738155

  3. Marco (Medical Record Communications) - System Concept, Design and Evaluation

    PubMed Central

    Moffatt, P. H.; Heisler, B. D.; Mela, W. D.; Alpert, J. J.; Goldstein, H.M.

    1978-01-01

    MARCO, an interfacility communication system, has been designed to promote safe relevant health care delivery to the inner city pediatric patient receiving care in a network consisting of Boston City Hospital and its affiliated Neighborhood Health Centers. This application of computer technology to communication of medical information compiled on an individual patient in multiple locations has implications for private group practice as well as other urban networks similar to our own. This paper provides the MARCO system concept, the system design and evaluation of its success after two years of operation.

  4. Typewriting: Toward Duplicating Success

    ERIC Educational Resources Information Center

    Orsborn, Karen J.

    1977-01-01

    A description of two projects (secretarial handbook and memo pad and personalized stationery) for use in teaching the duplication process that will capture the interests of students in an advanced typewriting class. (HD)

  5. Method and system for determining precursors of health abnormalities from processing medical records

    DOEpatents

    Patton, Robert M; Potok, Thomas E; Beckerman, Barbara G

    2013-06-25

    Medical reports are converted to document vectors in computing apparatus and sampled by applying a maximum variation sampling function including a fitness function to the document vectors to reduce a number of medical records being processed and to increase the diversity of the medical records being processed. Linguistic phrases are extracted from the medical records and converted to s-grams. A Haar wavelet function is applied to the s-grams over the preselected time interval; and the coefficient results of the Haar wavelet function are examined for patterns representing the likelihood of health abnormalities. This confirms certain s-grams as precursors of the health abnormality and a parameter can be calculated in relation to the occurrence of such a health abnormality.

  6. Architecture of portable electronic medical records system integrated with streaming media.

    PubMed

    Chen, Wei; Shih, Chien-Chou

    2012-02-01

    Due to increasing occurrence of accidents and illness during business trips, travel, or overseas studies, the requirement for portable EMR (Electronic Medical Records) has increased. This study proposes integrating streaming media technology into the EMR system to facilitate referrals, contracted laboratories, and disease notification among hospitals. The current study encoded static and dynamic medical images of patients into a streaming video format and stored them in a Flash Media Server (FMS). Based on the Taiwan Electronic Medical Record Template (TMT) standard, EMR records can be converted into XML documents and used to integrate description fields with embedded streaming videos. This investigation implemented a web-based portable EMR interchanging system using streaming media techniques to expedite exchanging medical image information among hospitals. The proposed architecture of the portable EMR retrieval system not only provides local hospital users the ability to acquire EMR text files from a previous hospital, but also helps access static and dynamic medical images as reference for clinical diagnosis and treatment. The proposed method protects property rights of medical images through information security mechanisms of the Medical Record Interchange Service Center and Health Certificate Authorization to facilitate proper, efficient, and continuous treatment of patients. PMID:20703752

  7. Automated tools for phenotype extraction from medical records.

    PubMed

    Yetisgen-Yildiz, Meliha; Bejan, Cosmin A; Vanderwende, Lucy; Xia, Fei; Evans, Heather L; Wurfel, Mark M

    2013-01-01

    Clinical research studying critical illness phenotypes relies on the identification of clinical syndromes defined by consensus definitions. Historically, identifying phenotypes has required manual chart review, a time and resource intensive process. The overall research goal of C ritical I llness PH enotype E xt R action (deCIPHER) project is to develop automated approaches based on natural language processing and machine learning that accurately identify phenotypes from EMR. We chose pneumonia as our first critical illness phenotype and conducted preliminary experiments to explore the problem space. In this abstract, we outline the tools we built for processing clinical records, present our preliminary findings for pneumonia extraction, and describe future steps. PMID:24303281

  8. Validity of a hospital-based obstetric register using medical records as reference

    PubMed Central

    Brixval, Carina Sjöberg; Thygesen, Lau Caspar; Johansen, Nanna Roed; Rørbye, Christina; Weber, Tom; Due, Pernille; Koushede, Vibeke

    2015-01-01

    Background Data from hospital-based registers and medical records offer valuable sources of information for clinical and epidemiological research purposes. However, conducting high-quality epidemiological research requires valid and complete data sources. Objective To assess completeness and validity of a hospital-based clinical register – the Obstetric Database – using a national register and medical records as references. Methods We assessed completeness of a hospital-based clinical register – the Obstetric Database – by linking data from all women registered in the Obstetric Database as having given birth in 2013 to the National Patient Register with coverage of all births in 2013. Validity of eleven selected indicators from the Obstetric Database was assessed using medical records as a golden standard. Using a random sample of 250 medical records, we calculated proportion of agreement, sensitivity, specificity, and positive and negative predictive values for each indicator. Two assessors independently reviewed medical records and inter-rater reliability was calculated as proportion of agreement and Cohen’s κ coefficient. Results We found 100% completeness of the Obstetric Database when compared to the Danish National Patient Register. Except for one delivery all 6,717 deliveries were present in both registers. Proportion of agreement between the Obstetric Database and medical records ranged from 91.1% to 99.6% for the eleven indicators. The validity measures ranged from 0.70 to 1.00 indicating high validity of the Obstetric Database. κ coefficients from the inter-rater reliability ranged from 0.71 to 1.00. Conclusion Completeness and validity of the Obstetric Database were found acceptable when using the National Patient Register and medical records as golden standards. The Obstetric Database therefore offers a valuable source for examining clinical, administrative, and research questions. PMID:26648757

  9. Giving Patients Access to Their Medical Records via the Internet

    PubMed Central

    Masys, Daniel; Baker, Dixie; Butros, Amy; Cowles, Kevin E.

    2002-01-01

    Objective: The Patient-Centered Access to Secure Systems Online (pcasso) project is designed to apply state-of-the-art-security to the communication of clinical information over the Internet. Design: The authors report the legal and regulatory issues associated with deploying the system, and results of its use by providers and patients. Human subject protection concerns raised by the Institutional Review Board focused on three areas—unauthorized access to information by persons other than the patient; the effect of startling or poorly understood information; and the effect of patient access to records on the record-keeping behavior of providers. Measurements: Objective and subjective measures of security and usability were obtained. Results: During its initial deployment phase, the project enrolled 216 physicians and 41 patients; of these, 68 physicians and 26 patients used the system one or more times. The system performed as designed, with no unauthorized information access or intrusions detected. Providers rated the usability of the system low because of the complexity of the secure login and other security features and restrictions limiting their access to those patients with whom they had a professional relationship. In contrast, patients rated the usability and functionality of the system favorably. Conclusion: High-assurance systems that serve both patients and providers will need to address differing expectations regarding security and ease of use. PMID:11861633

  10. Auditing Medical Records Accesses via Healthcare Interaction Networks

    PubMed Central

    Chen, You; Nyemba, Steve; Malin, Bradley

    2012-01-01

    Healthcare organizations are deploying increasingly complex clinical information systems to support patient care. Traditional information security practices (e.g., role-based access control) are embedded in enterprise-level systems, but are insufficient to ensure patient privacy. This is due, in part, to the dynamic nature of healthcare, which makes it difficult to predict which care providers need access to what and when. In this paper, we show that modeling operations at a higher level of granularity (e.g., the departmental level) are stable in the context of a relational network, which may enable more effective auditing strategies. We study three months of access logs from a large academic medical center to illustrate that departmental interaction networks exhibit certain invariants, such as the number, strength, and reciprocity of relationships. We further show that the relations extracted from the network can be leveraged to assess the extent to which a patient’s care satisfies expected organizational behavior. PMID:23304277

  11. Auditing medical records accesses via healthcare interaction networks.

    PubMed

    Chen, You; Nyemba, Steve; Malin, Bradley

    2012-01-01

    Healthcare organizations are deploying increasingly complex clinical information systems to support patient care. Traditional information security practices (e.g., role-based access control) are embedded in enterprise-level systems, but are insufficient to ensure patient privacy. This is due, in part, to the dynamic nature of healthcare, which makes it difficult to predict which care providers need access to what and when. In this paper, we show that modeling operations at a higher level of granularity (e.g., the departmental level) are stable in the context of a relational network, which may enable more effective auditing strategies. We study three months of access logs from a large academic medical center to illustrate that departmental interaction networks exhibit certain invariants, such as the number, strength, and reciprocity of relationships. We further show that the relations extracted from the network can be leveraged to assess the extent to which a patient's care satisfies expected organizational behavior. PMID:23304277

  12. Developing a Fully Integrated Medical Transport Record to Support Comparative Effectiveness Research for Patients Undergoing Medical Transport

    PubMed Central

    Reimer, Andrew P.; Madigan, Elizabeth

    2013-01-01

    The consolidation of health care systems to develop centers of clinical excellence has led to an increased reliance on medical transport to move patients requiring time-sensitive interventions and specialized treatments. There is a paucity of outcomes data, specifically comparative effectiveness research, related to the efficacy of different transport services and the overall morbidity and mortality of patients that undergo medical transfer. The rapid development of electronic medical record (EMR) use has also occurred with transport charting. However, limited studies have incorporated transport chart data in outcomes analyses. We have begun development of a fully integrated medical transport record, combining transport and hospitals EMRs, to support research efforts and develop clinical decision support tools for transported patients. In this paper, we describe the elements necessary to develop a fully integrated medical transport EMR to support the conduct of comparative effectiveness research, outline the current limitations and challenges, and provide insight into the future direction in developing clinical decision support tools for patients requiring transport. PMID:25848576

  13. Semantic extraction and processing of medical records for patient-oriented visual index

    NASA Astrophysics Data System (ADS)

    Zheng, Weilin; Dong, Wenjie; Chen, Xiangjiao; Zhang, Jianguo

    2012-02-01

    To have comprehensive and completed understanding healthcare status of a patient, doctors need to search patient medical records from different healthcare information systems, such as PACS, RIS, HIS, USIS, as a reference of diagnosis and treatment decisions for the patient. However, it is time-consuming and tedious to do these procedures. In order to solve this kind of problems, we developed a patient-oriented visual index system (VIS) to use the visual technology to show health status and to retrieve the patients' examination information stored in each system with a 3D human model. In this presentation, we present a new approach about how to extract the semantic and characteristic information from the medical record systems such as RIS/USIS to create the 3D Visual Index. This approach includes following steps: (1) Building a medical characteristic semantic knowledge base; (2) Developing natural language processing (NLP) engine to perform semantic analysis and logical judgment on text-based medical records; (3) Applying the knowledge base and NLP engine on medical records to extract medical characteristics (e.g., the positive focus information), and then mapping extracted information to related organ/parts of 3D human model to create the visual index. We performed the testing procedures on 559 samples of radiological reports which include 853 focuses, and achieved 828 focuses' information. The successful rate of focus extraction is about 97.1%.

  14. Inferring Clinical Workflow Efficiency via Electronic Medical Record Utilization

    PubMed Central

    Chen, You; Xie, Wei; Gunter, Carl A; Liebovitz, David; Mehrotra, Sanjay; Zhang, He; Malin, Bradley

    2015-01-01

    Complexity in clinical workflows can lead to inefficiency in making diagnoses, ineffectiveness of treatment plans and uninformed management of healthcare organizations (HCOs). Traditional strategies to manage workflow complexity are based on measuring the gaps between workflows defined by HCO administrators and the actual processes followed by staff in the clinic. However, existing methods tend to neglect the influences of EMR systems on the utilization of workflows, which could be leveraged to optimize workflows facilitated through the EMR. In this paper, we introduce a framework to infer clinical workflows through the utilization of an EMR and show how such workflows roughly partition into four types according to their efficiency. Our framework infers workflows at several levels of granularity through data mining technologies. We study four months of EMR event logs from a large medical center, including 16,569 inpatient stays, and illustrate that over approximately 95% of workflows are efficient and that 80% of patients are on such workflows. At the same time, we show that the remaining 5% of workflows may be inefficient due to a variety of factors, such as complex patients. PMID:26958173

  15. A scheme for assuring lifelong readability in computer based medical records.

    PubMed

    Matsumura, Yasushi; Kurabayashi, Noriyuki; Iwasaki, Tetsuya; Sugaya, Shuichi; Ueda, Kanayo; Mineno, Takahiro; Takeda, Hiroshi

    2010-01-01

    Medical records must be kept over an extended period of time, meanwhile computer based medical records are renewed every 5-6 years. Readability of medical records must be assured even though the systems are renewed by different vendors. To achieve this, we proposed a method called DACS, in which a medical record is considered as an aggregation of documents. A Document generated by a system is transformed to a format read by free software such as PDF, which is transferred with the document meta-information and important data written on the XML to the Document Deliverer. It stores these data into the Document Archiver, the Document Sharing Server and the Data Warehouse (DWH). We developed the Matrix View which shows documents in chronological order, and the Tree View showing documents in class tree structure. By this method all the documents can be integrated and be viewed by a single viewer. This helps users figure out patient history and find a document being sought. In addition, documents' data can be shared among systems and analyzed by DWH. Most importantly DACS can assure the lifelong readability of medical records. PMID:20841656

  16. Workflow and Electronic Health Records in Small Medical Practices

    PubMed Central

    Ramaiah, Mala; Subrahmanian, Eswaran; Sriram, Ram D; Lide, Bettijoyce B

    2012-01-01

    This paper analyzes the workflow and implementation of electronic health record (EHR) systems across different functions in small physician offices. We characterize the differences in the offices based on the levels of computerization in terms of workflow, sources of time delay, and barriers to using EHR systems to support the entire workflow. The study was based on a combination of questionnaires, interviews, in situ observations, and data collection efforts. This study was not intended to be a full-scale time-and-motion study with precise measurements but was intended to provide an overview of the potential sources of delays while performing office tasks. The study follows an interpretive model of case studies rather than a large-sample statistical survey of practices. To identify time-consuming tasks, workflow maps were created based on the aggregated data from the offices. The results from the study show that specialty physicians are more favorable toward adopting EHR systems than primary care physicians are. The barriers to adoption of EHR systems by primary care physicians can be attributed to the complex workflows that exist in primary care physician offices, leading to nonstandardized workflow structures and practices. Also, primary care physicians would benefit more from EHR systems if the systems could interact with external entities. PMID:22737096

  17. Validation of a medical record-based delirium risk assessment

    PubMed Central

    Rudolph, James L.; Harrington, Mary Beth; Lucatorto, Michelle A.; Chester, Jennifer G.; Francis, Joseph; Shay, Kenneth

    2016-01-01

    Objectives To improve identification of patients at high risk for delirium, this study developed a chart abstraction tool for delirium risk and validated the tool against clinical expert diagnosis of delirium Design Prospective Cohort Study Setting Tertiary VA Hospital in New England Participants 100 Veterans admitted to the medical service Measurements While admitted, each participant underwent serial assessments for delirium by a clinical expert. Using the four criteria of a validated delirium prediction rule (e.g. cognitive impairment, sensory deficit, severe illness, and dehydration), chart review terms were selected for each criteria and delirium risk was the sum of criteria present (range 0–4; 4-worst). After discharge, the chart tool was completed by a nurse blinded to the expert’s diagnosis. Results The participants (n=100) were largely older (mean age 81 ±7years) men (94% male) and 23% developed overall delirium (14% incident). The rate of overall delirium in participants with 0, 1–2, and 3–4 risk factors was 11%, 18%, and 50% (p=.01) respectively with a c-statistic of 0.65 (95% Confidence Interval 0.54, 0.76). For incident delirium, the rate was 11%, 13%, and 25% (p=.53) and the c-statistic of 0.56 (95%CI 0.42, 0.74). Discharge to a rehabilitation center or nursing home increased with increasing delirium risk (0%, 18%, 60%, p=.02). Conclusions A chart abstraction tool was effective at identifying overall delirium risk, but not incident delirium risk. While the tool cannot replace clinical assessment and diagnosis of delirium, the use of this tool as an educational, clinical, or quality measurement aid warrants additional study. PMID:22091575

  18. Organising European technical documentation to avoid duplication.

    PubMed

    Donawa, Maria

    2006-04-01

    The development of comprehensive accurate and well-organised technical documentation that demonstrates compliance with regulatory requirements is a resource-intensive, but critically important activity for medical device manufacturers. This article discusses guidance documents and method of organising technical documentation that may help avoid costly and time-consuming duplication. PMID:16736662

  19. Designing an Algorithm to Preserve Privacy for Medical Record Linkage With Error-Prone Data

    PubMed Central

    Pal, Doyel; Chen, Tingting; Khethavath, Praveen

    2014-01-01

    Background Linking medical records across different medical service providers is important to the enhancement of health care quality and public health surveillance. In records linkage, protecting the patients’ privacy is a primary requirement. In real-world health care databases, records may well contain errors due to various reasons such as typos. Linking the error-prone data and preserving data privacy at the same time are very difficult. Existing privacy preserving solutions for this problem are only restricted to textual data. Objective To enable different medical service providers to link their error-prone data in a private way, our aim was to provide a holistic solution by designing and developing a medical record linkage system for medical service providers. Methods To initiate a record linkage, one provider selects one of its collaborators in the Connection Management Module, chooses some attributes of the database to be matched, and establishes the connection with the collaborator after the negotiation. In the Data Matching Module, for error-free data, our solution offered two different choices for cryptographic schemes. For error-prone numerical data, we proposed a newly designed privacy preserving linking algorithm named the Error-Tolerant Linking Algorithm, that allows the error-prone data to be correctly matched if the distance between the two records is below a threshold. Results We designed and developed a comprehensive and user-friendly software system that provides privacy preserving record linkage functions for medical service providers, which meets the regulation of Health Insurance Portability and Accountability Act. It does not require a third party and it is secure in that neither entity can learn the records in the other’s database. Moreover, our novel Error-Tolerant Linking Algorithm implemented in this software can work well with error-prone numerical data. We theoretically proved the correctness and security of our Error

  20. The role of frontline RNs in the selection of an electronic medical record business partner.

    PubMed

    Wilhoit, Kathryn; Mustain, Jane; King, Marjorie

    2006-01-01

    Frontline RNs knowledgeable in the strategic objectives of their organization made a difference in the selection of an electronic medical record business partner for a large, complex healthcare system. Their impact was significant because of the chief nurse executive's personal articulation of the organization's strategic goals and of her investment in their education. These factors provided the frontline RNs with a foundational base of knowledge about a variety of electronic medical record systems. The preparation and exposure enabled the frontline RNs to make a valuable contribution to the selection of an electronic medical record business partner. The RNs were a major force in affecting philosophical change from the organization's original pursuit of "best-of-breed" interfaced systems to a fully integrated, "best-of-class" vendor business partner. The learning experiences of the frontline RNs are explored to answer the following question: Why must frontline RNs play a key role in this process? PMID:16849913

  1. University of Arkansas for Medical Sciences electronic health record and medical informatics training for undergraduate health professionals*

    PubMed Central

    Hart, Jan K; Newton, Bruce W; Boone, Steven E

    2010-01-01

    The University of Arkansas for Medical Sciences (UAMS) is planning interprofessional training in electronic health records (EHRs) and medical informatics. Training will be integrated throughout the curricula and will include seminars on broad concepts supplemented with online modules, didactic lectures, and hands-on experiences. Training will prepare future health professionals to use EHRs, evidence-based medicine, medical decision support, and point-of-care tools to reduce errors, improve standards of care, address Health Insurance Portability and Accountability Act requirements and accreditation standards, and promote appropriate documentation to enable data retrieval for clinical research. UAMS will ensure that graduates are ready for the rapidly evolving practice environment created by the HITECH Act. PMID:20648253

  2. [Design and Implementation of a Mobile Operating Room Information Management System Based on Electronic Medical Record].

    PubMed

    Liu, Baozhen; Liu, Zhiguo; Wang, Xianwen

    2015-06-01

    A mobile operating room information management system with electronic medical record (EMR) is designed to improve work efficiency and to enhance the patient information sharing. In the operating room, this system acquires the information from various medical devices through the Client/Server (C/S) pattern, and automatically generates XML-based EMR. Outside the operating room, this system provides information access service by using the Browser/Server (B/S) pattern. Software test shows that this system can correctly collect medical information from equipment and clearly display the real-time waveform. By achieving surgery records with higher quality and sharing the information among mobile medical units, this system can effectively reduce doctors' workload and promote the information construction of the field hospital. PMID:26485982

  3. 76 FR 53921 - Privacy Act of 1974; Department of Homeland Security ALL-034 Emergency Care Medical Records...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-08-30

    ... employees, their records are considered part of the OPM/GOVT-10--Employee Medical File System Records, 71 FR... considered part of the OPM/GOVT- ] 10--Employee Medical File System Records, 71 FR 35360 (Jun. 19, 2006... SECURITY Office of the Secretary Privacy Act of 1974; Department of Homeland Security ALL--034...

  4. FRR: fair remote retrieval of outsourced private medical records in electronic health networks.

    PubMed

    Wang, Huaqun; Wu, Qianhong; Qin, Bo; Domingo-Ferrer, Josep

    2014-08-01

    Cloud computing is emerging as the next-generation IT architecture. However, cloud computing also raises security and privacy concerns since the users have no physical control over the outsourced data. This paper focuses on fairly retrieving encrypted private medical records outsourced to remote untrusted cloud servers in the case of medical accidents and disputes. Our goal is to enable an independent committee to fairly recover the original private medical records so that medical investigation can be carried out in a convincing way. We achieve this goal with a fair remote retrieval (FRR) model in which either t investigation committee members cooperatively retrieve the original medical data or none of them can get any information on the medical records. We realize the first FRR scheme by exploiting fair multi-member key exchange and homomorphic privately verifiable tags. Based on the standard computational Diffie-Hellman (CDH) assumption, our scheme is provably secure in the random oracle model (ROM). A detailed performance analysis and experimental results show that our scheme is efficient in terms of communication and computation. PMID:24560680

  5. Design and implementation of web-based mobile electronic medication administration record.

    PubMed

    Hsieh, Sung-Huai; Hou, I-Ching; Cheng, Po-Hsun; Tan, Ching-Ting; Shen, Po-Chao; Hsu, Kai-Ping; Hsieh, Sheau-Ling; Lai, Feipei

    2010-10-01

    Patients' safety is the most essential, critical issue, however, errors can hardly prevent, especially for human faults. In order to reduce the errors caused by human, we construct Electronic Health Records (EHR) in the Health Information System (HIS) to facilitate patients' safety and to improve the quality of medical care. During the medical care processing, all the tasks are based upon physicians' orders. In National Taiwan University Hospital (NTUH), the Electronic Health Record committee proposed a standard of order flows. There are objectives of the standard: first, to enhance medical procedures and enforce hospital policies; secondly, to improve the quality of medical care; third, to collect sufficient, adequate data for EHR in the near future. Among the proposed procedures, NTUH decides to establish a web-based mobile electronic medication administration record (ME-MAR) system. The system, build based on the service-oriented architecture (SOA) as well as embedded the HL7/XML standard, is installed in the Mobile Nursing Carts. It also implement accompany with the advanced techniques like Asynchronous JavaScript and XML (Ajax) or Web services to enhance the system usability. According to researches, it indicates that medication errors are highly proportion to total medical faults. Therefore, we expect the ME-MAR system can reduce medication errors. In addition, we evaluate ME-MAR can assist nurses or healthcare practitioners to administer, manage medication properly. This successful experience of developing the NTUH ME-MAR system can be easily applied to other related system. Meanwhile, the SOA architecture of the system can also be seamless integrated to NTUH or other HIS system. PMID:20703613

  6. Interstitial duplication 19p

    SciTech Connect

    Stratton, R.F.; DuPont, B.R.; Moore, C.M.

    1995-07-17

    We report on a 9-month-old girl with an interstitial duplication of 19p, developmental delay, and multiple anomalies including bifrontal prominence, obtuse frontonasal angle, short columella, additional midline philtral pillar, midline ridge on the tongue, vertical midline ridge at the mental symphysis, and a complex congenital heart defect including severe branch pulmonary artery stenosis, secundum atrial septal defect (ASD), and several ventricular septal defects (VSDs). Use of fluorescent in situ hybridization (FISH) with chromosome 19- specific probes showed a direct duplication of bands 19p13.13 and 19p13.2. 6 refs., 1 fig.

  7. An electronic health record driven algorithm to identify incident antidepressant medication users

    PubMed Central

    Bobo, William V; Pathak, Jyotishman; Kremers, Hilal Maradit; Yawn, Barbara P; Brue, Scott M; Stoppel, Cynthia J; Croarkin, Paul E; St Sauver, Jennifer; Frye, Mark A; Rocca, Walter A

    2014-01-01

    Objective We validated an algorithm designed to identify new or prevalent users of antidepressant medications via population-based drug prescription records. Patients and methods We obtained population-based drug prescription records for the entire Olmsted County, Minnesota, population from 2011 to 2012 (N=149 629) using the existing electronic medical records linkage infrastructure of the Rochester Epidemiology Project (REP). We selected electronically a random sample of 200 new antidepressant users stratified by age and sex. The algorithm required the exclusion of antidepressant use in the 6 months preceding the date of the first qualifying antidepressant prescription (index date). Medical records were manually reviewed and adjudicated to calculate the positive predictive value (PPV). We also manually reviewed the records of a random sample of 200 antihistamine users who did not meet the case definition of new antidepressant user to estimate the negative predictive value (NPV). Results 161 of the 198 subjects electronically identified as new antidepressant users were confirmed by manual record review (PPV 81.3%). Restricting the definition of new users to subjects who were prescribed typical starting doses of each agent for treating major depression in non-geriatric adults resulted in an increase in the PPV (90.9%). Extending the time windows with no antidepressant use preceding the index date resulted in only modest increases in PPV. The manual abstraction of medical records of 200 antihistamine users yielded an NPV of 98.5%. Conclusions Our study confirms that REP prescription records can be used to identify prevalent and incident users of antidepressants in the Olmsted County, Minnesota, population. PMID:24780720

  8. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  9. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 10 Energy 1 2011-01-01 2011-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  10. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 10 Energy 1 2013-01-01 2013-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  11. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  12. 10 CFR 7.21 - Cost of duplication of documents.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 10 Energy 1 2012-01-01 2012-01-01 false Cost of duplication of documents. 7.21 Section 7.21 Energy NUCLEAR REGULATORY COMMISSION ADVISORY COMMITTEES § 7.21 Cost of duplication of documents. Copies of the records, reports, transcripts, minutes, appendices, working papers, drafts, studies, agenda, or...

  13. The evolution of office notes and the electronic medical record: The CAPS note.

    PubMed

    Styron, Joseph F; Evans, Peter J

    2016-07-01

    The advent of the electronic medical record (EMR) combined with an expansion of information required by medicolegal and billing departments has transformed the progress note from a succinct note into an often unwieldy data-dump unable to concisely convey the physician's medical reasoning. We describe a new note format--CAPS, which stands for concern, assessment, plan, and supporting data--to streamline the communication of the patient's problem, the practitioner's assessment and plan, and the medical reasoning to support the plan. PMID:27399867

  14. International Classification of Impairments, Disabilities and Handicaps: exercises in its application in a hospital medical record.

    PubMed

    Ford, B

    1984-01-01

    The principles and philosophies of the WHO International Classification of Impairments, Disabilities and Handicaps were enthusiastically espoused by all staff of a large rehabilitation hospital. It was universally seen as an accurate and standardized way of recording and reporting a patient's functional state and opened up opportunities for research between causation and consequences of diseases, the relations of impairments to handicaps, and so on. In short, it promised a hard data base about disability, which presently has been studied only anecdotally, or by large random community samples. The joy of the principle turned into torment when the attempts to apply the system to current and past medical records were made. Retrospective codification of existing records was found to be virtually impossible. Recorded data were patchy, insufficiently precise to translate into IDH codes and the codifier had to make so many value judgements, interpretations and guesses to squeeze what was written on the record into IDH codes. A totally new and disciplined way of making notations in medical records would be required to make this method applicable, and such a discipline presents challenges to the medical administrator which dwarfs the production of the WHO manual.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:6241185

  15. Fast Model Adaptation for Automated Section Classification in Electronic Medical Records.

    PubMed

    Ni, Jian; Delaney, Brian; Florian, Radu

    2015-01-01

    Medical information extraction is the automatic extraction of structured information from electronic medical records, where such information can be used for improving healthcare processes and medical decision making. In this paper, we study one important medical information extraction task called section classification. The objective of section classification is to automatically identify sections in a medical document and classify them into one of the pre-defined section types. Training section classification models typically requires large amounts of human labeled training data to achieve high accuracy. Annotating institution-specific data, however, can be both expensive and time-consuming; which poses a big hurdle for adapting a section classification model to new medical institutions. In this paper, we apply two advanced machine learning techniques, active learning and distant supervision, to reduce annotation cost and achieve fast model adaptation for automated section classification in electronic medical records. Our experiment results show that active learning reduces the annotation cost and time by more than 50%, and distant supervision can achieve good model accuracy using weakly labeled training data only. PMID:26262005

  16. 20 CFR 30.113 - What are the requirements for written medical documentation, contemporaneous records, and other...

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... the medical records containing a diagnosis and date of diagnosis of a covered medical condition no longer exist, then OWCP may consider other evidence to establish a diagnosis and date of diagnosis of...

  17. 20 CFR 30.113 - What are the requirements for written medical documentation, contemporaneous records, and other...

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... the medical records containing a diagnosis and date of diagnosis of a covered medical condition no longer exist, then OWCP may consider other evidence to establish a diagnosis and date of diagnosis of...

  18. Evaluation of Unpreparedness When Issuing Copies of Medical Records in Tertiary Referral Hospitals

    PubMed Central

    Moon, Myong-Mo; Seo, Sun-Won; Park, Woo-Sung; Kim, Yoon; Kim, Sung-Soo; Choi, Eun-Mi; Park, Jong; Park, Il-Soon

    2010-01-01

    Objectives As a baseline study to aid in the development of proper policy, we investigated the current condition of unpreparedness of documents required when issuing copies of medical records and related factors. Methods The study was comprised of 7,203 cases in which copies of medical records were issued from July 1st, 2007 through June 30th, 2008 to 5 tertiary referral hospitals. Data from these hospitals was collected using their established electronic databases and included study variables such as unpreparedness of the required documents as a dependent variable and putative covariates. Results The rate of unpreparedness of required documents was 14.9%. Multiple logistic regression analysis revealed the following factors as being related to the high rate of unpreparedness: patient age (older patients had a higher rate), issuance channels (on admission > via out-patient clinic), type of applicant (others such as family members > for oneself > insurers), type of original medical record (utilization records on admission > other records), issuance purpose (for providing insurer > medical use), residential area of applicant (Seoul > Honam province and Jeju), and number of copied documents (more documents gave a lower rate). The rate of unpreparedness differed significantly among the hospitals; suggesting that they may have followed their own conventional protocols rather than legal procedures in some cases. Conclusions The study results showed that the level of compliance to the required legal procedure was high, but that problems occurred in assuring the safety of the medical information. A proper legislative approach is therefore required to balance the security of and access to medical information. PMID:21818431

  19. [A method for auditing medical records quality: audit of 467 medical records within the framework of the medical information systems project quality control].

    PubMed

    Boulay, F; Chevallier, T; Gendreike, Y; Mailland, V; Joliot, Y; Sambuc, R

    1998-03-01

    Future hospital accreditation could take into account the quality of medical files. The objectives of this study is to test a method for auditing and evaluating the quality of the handing of medical files. We conducted a retrospective regional audit based on the frame of reference the National Agency for Medical Development and Evaluation, by using a sample of cases, stratified by establishment. In our region, the global budgets of 47 public and private hospitals participating in the public hospital service, are adjusted while keeping in mind the medicalised activity data (PMSI). This audit was proposed to the doctors of the Department of Medical Information on the occasion of the regulatory PMSI quality control. A total of 467 questionnaires were given by 39 of the 47 sollicited hospitals (83%). The methodological aspects (questionnaire, cooperative approach...) are discussed. The make-up of medical files can alos be improved by raising the percentage of the presence of important data or documents such as the reason for admission (74.1%), the surgery report (83.2%), and the hospitalisation report (66.6%). A system for classifying the paraclinical results is shared and systematic throughout the service or hospital in only 73.2% of cases. The quality of the handing of medical files seems problematic in our hospitals and actions for improving the quality should be undertaken as a priority. PMID:9685806

  20. Assessing Reliability of Medical Record Reviews for the Detection of Hospital Adverse Events

    PubMed Central

    Ock, Minsu; Lee, Sang-il; Jo, Min-Woo; Lee, Jin Yong; Kim, Seon-Ha

    2015-01-01

    Objectives: The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events. Methods: We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later. Results: In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89). Conclusions: In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study. PMID:26429290