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Sample records for psychiatric medical record

  1. 32 CFR 1701.13 - Special procedures for medical/psychiatric/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/psychiatric... 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...

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

    ... 32 National Defense 6 2013-07-01 2013-07-01 false Special procedures for medical/psychiatric... 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 1701.13 - Special procedures for medical/psychiatric/psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... access to their medical, psychiatric or psychological testing records by writing to: Information and.../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,...

  5. 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...

  6. 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 requirements for psychiatric hospitals. 482.61 Section 482.61 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS...

  7. Access to Medical and Psychiatric Records: Proposed Legislation

    ERIC Educational Resources Information Center

    Felch, Erica

    1976-01-01

    This commentary reviews the history and ideology of nondisclosure, considers the realities of modern treatment and record-keeping, and describes the contemporary legal dilemma in this context. Model legislation is proposed to provide patients a property right of direct access to their records. (LBH)

  8. Implementation and Impact of Psychiatric Electronic Medical Records in a Public Medical Center

    PubMed Central

    Xiao, Anna Q.; Acosta, Frank X.

    2016-01-01

    Objectives This study describes the efforts to implement electronic charting in a large public psychiatric outpatient clinic with the objective to improve clinical documentation. Methods Data made available through the quality review process are utilized to evaluate the effectiveness of the electronic intervention. The study is a comparative analysis of the three years before and three years after the point of implementation of electronic charting. Results Statistical analyses indicate significant findings (p <.0001) in the comparison of the periods before and after implementation in terms of note completion and documentation of medication management, supporting the study's hypothesis that electronic intervention will improve the quality of clinical documentation. Conclusions This study contributes new knowledge to improve our understanding of the barriers and benefits of implementing and maintaining electronic charting in mental health settings. PMID:27843422

  9. 28 CFR 549.42 - Use of psychiatric medications.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Use of psychiatric medications. 549.42... MEDICAL SERVICES Psychiatric Evaluation and Treatment § 549.42 Use of psychiatric medications. Psychiatric..., for which such medication is accepted treatment. Psychiatric medication will be administered...

  10. 28 CFR 549.42 - Use of psychiatric medications.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Use of psychiatric medications. 549.42... MEDICAL SERVICES Psychiatric Evaluation and Treatment § 549.42 Use of psychiatric medications. Psychiatric..., for which such medication is accepted treatment. Psychiatric medication will be administered...

  11. 28 CFR 549.42 - Use of psychiatric medications.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Use of psychiatric medications. 549.42... MEDICAL SERVICES Psychiatric Evaluation and Treatment § 549.42 Use of psychiatric medications. Psychiatric..., for which such medication is accepted treatment. Psychiatric medication will be administered...

  12. [Psychiatric advance directives--medical models into psychiatric medicine].

    PubMed

    Mautner, Sigal; Lachman, Max; Kaplan, Zeev; Shalev, Anat

    2014-01-01

    Since the year 2005, in the field of general medicine, the legislature in Israel determined ways to implement medically advanced directives according to the power of the law. Different states in the world had implemented parallel legislation for patients who suffer from mental illness. Psychiatric Advance Directives is a legitimate document which is valid in Australia, New Zealand, Scotland, England and in 25 countries in the U.S.A. Psychiatric advance directives (PAD's) allow competent persons, through advance instructions, to state their preferences for future mental health treatment in the event of an incapacitating psychiatric crisis. Self Determination Theory, Self Care and Autonomy are dominant supportive approaches in the creation of Psychiatric Advance Directives. Research conducted on psychiatric advance directives shows positive potential benefits for mental health clients, therapists and psychiatrists. More research in that area must be conducted. Psychiatric advance directives are currently developed and implemented with the cooperation of the Tauber Foundation and the Beer Sheva Mental Health Center. This is the first step in learning of effective ways to use this intervention in Israel and change perceptions toward a positive connection between medical efficiency and client preferences.

  13. Psychiatric presentations/manifestations of medical illnesses.

    PubMed

    Castro, Jack; Billick, Stephen

    2013-09-01

    Psychiatry is clearly an integral part of medicine. With a history and physical exam (called the mental status exam in psychiatry), appropriate laboratory or imaging studies, a differential diagnosis is made. If a specific DSM-IV-TR diagnosis is made, then the treatment will naturally follow. The diagnoses are scientifically established with good validity, specificity, sensitivity and inter-rater reliability. Similarly the treatments are established through scientific research. However, sometimes medical illnesses may present with symptoms seemingly pointing to a psychiatric origin. Making a misdiagnosis can be quite problematic and dangerous for the patient. The opposite is also true, that psychiatric illnesses may present with symptoms implying a medical diagnostic origin. Finally, psychiatric patients may have more than one psychiatric diagnosis and in addition, a medical diagnosis too. A high degree of suspicion should always be entertained by the diagnosing physician, psychiatric or non-psychiatric. This paper reviews the literature regarding these situations and then presents several clinical cases where this conundrum was present. Making the correct diagnosis was critical in the successful treatment outcome of each of the clinical cases. When asked to consult on a patient by non-psychiatric physicians, the psychiatrist must be careful to also look for non-psychiatric origins for the referring symptoms. It is important for psychiatrists to build on their medical knowledge from medical school and internship and continue to be kept abreast of confounding symptomatology.

  14. Your Medical Records

    MedlinePlus

    ... Surgery? A Week of Healthy Breakfasts Shyness Your Medical Records KidsHealth > For Teens > Your Medical Records A ... Records? en español Tus historias clínicas What Are Medical Records? Each time you climb up on a ...

  15. Your Medical Records

    MedlinePlus

    ... sometimes, but many health care providers now keep electronic records. You might hear medical people call these EHRs — short for electronic health records . Electronic records make it easier for ...

  16. 42 CFR 456.482 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Medical, psychiatric, and social evaluations. 456... HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Inpatient Psychiatric..., psychiatric, and social evaluations. If a facility provides inpatient psychiatric services to a...

  17. 42 CFR 456.482 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 4 2011-10-01 2011-10-01 false Medical, psychiatric, and social evaluations. 456... HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Inpatient Psychiatric..., psychiatric, and social evaluations. If a facility provides inpatient psychiatric services to a...

  18. 42 CFR 456.482 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Medical, psychiatric, and social evaluations. 456... HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Inpatient Psychiatric..., psychiatric, and social evaluations. If a facility provides inpatient psychiatric services to a...

  19. 42 CFR 456.482 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Medical, psychiatric, and social evaluations. 456... HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Inpatient Psychiatric..., psychiatric, and social evaluations. If a facility provides inpatient psychiatric services to a...

  20. 42 CFR 456.482 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Medical, psychiatric, and social evaluations. 456... HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Inpatient Psychiatric..., psychiatric, and social evaluations. If a facility provides inpatient psychiatric services to a...

  1. Asperger Syndrome: Associated Psychiatric and Medical Conditions.

    ERIC Educational Resources Information Center

    Ghaziuddin, Mohammad

    2002-01-01

    This article explores the association of medical and psychiatric conditions with Asperger syndrome, based mainly on publications from the last two decades. It examines comorbidity of Asperger syndrome with mood disorders, schizophrenia, obsessive-compulsive disorder, attention deficit/hyperactivity disorder, tic disorders, violence and aggression,…

  2. 28 CFR 551.114 - Medical, psychiatric and psychological.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 28 Judicial Administration 2 2010-07-01 2010-07-01 false Medical, psychiatric and psychological... MANAGEMENT MISCELLANEOUS Pretrial Inmates § 551.114 Medical, psychiatric and psychological. (a) Staff shall provide the pretrial inmate with the same level of basic medical (including dental), psychiatric,...

  3. 28 CFR 551.114 - Medical, psychiatric and psychological.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 28 Judicial Administration 2 2013-07-01 2013-07-01 false Medical, psychiatric and psychological... MANAGEMENT MISCELLANEOUS Pretrial Inmates § 551.114 Medical, psychiatric and psychological. (a) Staff shall provide the pretrial inmate with the same level of basic medical (including dental), psychiatric,...

  4. 42 CFR 456.170 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Medical, psychiatric, and social evaluations. 456... Hospitals Medical, Psychiatric, and Social Evaluations and Admission Review § 456.170 Medical, psychiatric... beneficiary's need for care in the hospital; and appropriate professional personnel must make a...

  5. 28 CFR 551.114 - Medical, psychiatric and psychological.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 28 Judicial Administration 2 2014-07-01 2014-07-01 false Medical, psychiatric and psychological... MANAGEMENT MISCELLANEOUS Pretrial Inmates § 551.114 Medical, psychiatric and psychological. (a) Staff shall provide the pretrial inmate with the same level of basic medical (including dental), psychiatric,...

  6. 42 CFR 456.170 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Medical, psychiatric, and social evaluations. 456... Hospitals Medical, Psychiatric, and Social Evaluations and Admission Review § 456.170 Medical, psychiatric... beneficiary's need for care in the hospital; and appropriate professional personnel must make a...

  7. 42 CFR 456.170 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Medical, psychiatric, and social evaluations. 456... Hospitals Medical, Psychiatric, and Social Evaluations and Admission Review § 456.170 Medical, psychiatric... beneficiary's need for care in the hospital; and appropriate professional personnel must make a...

  8. 28 CFR 551.114 - Medical, psychiatric and psychological.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 28 Judicial Administration 2 2012-07-01 2012-07-01 false Medical, psychiatric and psychological... MANAGEMENT MISCELLANEOUS Pretrial Inmates § 551.114 Medical, psychiatric and psychological. (a) Staff shall provide the pretrial inmate with the same level of basic medical (including dental), psychiatric,...

  9. 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…

  10. 28 CFR 549.43 - Involuntary psychiatric treatment and medication.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... medication. 549.43 Section 549.43 Judicial Administration BUREAU OF PRISONS, DEPARTMENT OF JUSTICE INSTITUTIONAL MANAGEMENT MEDICAL SERVICES Administrative Safeguards for Psychiatric Treatment and Medication § 549.43 Involuntary psychiatric treatment and medication. Title 18 U.S.C. 4241-4247 and federal...

  11. The exclusion of people with psychiatric disorders from medical research.

    PubMed

    Humphreys, Keith; Blodgett, Janet C; Roberts, Laura Weiss

    2015-11-01

    People with psychiatric disorders are excluded from medical research to an unknown degree with unknown effects. We examined the prevalence of reported psychiatric exclusion criteria using a sample of 400 highly-cited randomized trials (2002-2010) across 20 common chronic disorders (6 psychiatric and 14 other medical disorders). Two coders rated the presence of psychiatric exclusion criteria for each trial. Half of all trials (and 84% of psychiatric disorder treatment trials) reported possible or definite psychiatric exclusion criteria, with significant variation across disorders (p < .001). Non-psychiatric conditions with high rates of reported psychiatric exclusion criteria included low back pain (75%), osteoarthritis (57%), COPD (55%), and diabetes (55%). The most commonly reported type of psychiatric exclusion criteria were those related to substance use disorders (reported in 48% of trials reporting at least one psychiatric exclusion criteria). General psychiatric exclusions (e.g., "any serious psychiatric disorder") were also prevalent (38% of trials). Psychiatric disorder trials were more likely than other medical disorder trials to report each specific type of psychiatric exclusion (p's < .001). Because published clinical trial reports do not always fully describe exclusion criteria, this study's estimates of the prevalence of psychiatric exclusion criteria are conservative. Clinical trials greatly influence state-of-the-art medical care, yet individuals with psychiatric disorders are often actively excluded from these trials. This pattern of exclusion represents an under-recognized and worrisome cause of health inequity. Further attention should be paid to how individuals with psychiatric disorders can be safely included in medical research to address this important clinical and social justice issue.

  12. 28 CFR 551.114 - Medical, psychiatric and psychological.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 28 Judicial Administration 2 2011-07-01 2011-07-01 false Medical, psychiatric and psychological... MANAGEMENT MISCELLANEOUS Pretrial Inmates § 551.114 Medical, psychiatric and psychological. (a) Staff shall... psychological care provided to convicted inmates. (b) Staff shall advise the court, through the U.S. Marshal,...

  13. Diagnosis and Medication Overload? A Nurse Review of the Psychiatric Histories of Older Youth in Treatment Foster Care

    ERIC Educational Resources Information Center

    Narendorf, Sarah Carter; Bertram, Julie; McMillen, J. Curtis

    2011-01-01

    Prior research has raised concern about the appropriateness of psychotropic medication use and the validity of psychiatric diagnosing for youth in child welfare but has lacked in-depth case information. This study reports results from a psychiatric nurse review conducted with eight youth entering a foster care intervention using case records and…

  14. [Administration of medication to use when needed and the care of psychiatric nursing].

    PubMed

    Estrela, Kelly da Silva Rocha; Loyola, Cristina Maria Douat

    2014-01-01

    This qualitative study aimed to analyze the clinical criteria used for the administration of prescribed medications for use when needed (SOS); and discuss the implication of the findings in this research to clinical psychiatric nursing. The records of female patients admitted to a psychiatric institution in the city of Rio de Janeiro, in the time frame from May to June 2009, were analyzed. In the 38 patient records, 16 prescriptions for medications SOS were found. The mean age of patients was around 45-55 years with a clinical diagnosis of Bipolar Mood Disorder. The medication category most prescribed as SOS was of benzodiazepines, followed by antipsychotics. It was noticed a tendency to not valuing the administration of medication in SOS notes. The study points out the importance to establish clinical criteria to indicate the need, or not, to administer prescribed SOS medications.

  15. Patient access to medical records.

    PubMed

    Mair, J L

    1996-01-01

    The issue of, and access to, medical records has been a contentious matter for some years in Australia. The recent High Court decision of Breen v Williams has clarified the law nationwide. The High Court confirmed that the ownership of medical records is vested in the creator of the records. The High Court further held that a patient has no right at law to access his or her medical records in the absence of any statute granting such a right, or other legal process.

  16. A review of trazodone use in psychiatric and medical conditions.

    PubMed

    Khouzam, Hani Raoul

    2017-01-01

    Trazodone is an antidepressant that is FDA-approved for the treatment of depression. It has been used by mental health and primary care providers for the treatment of multiple psychiatric and medical conditions .This review describes trazodone mechanism of action, formulation, dosage and adverse effects and then summarizes the beneficial effects of trazodone in the treatment of various psychiatric and medical conditions such as major depression, as well non-approved FDA indications such as insomnia,anxiety disorders, posttraumatic stress disorder, obsessive compulsive disorder, feeding and eating disorders, substance use disorders, behavioral disturbances associated with cognitive dysfunction, sexual dysfunction, certain pain conditions, and rehabilitation after acute ischemic stroke. Despite trazodone's favorable effects in the treatment of FDA-unapproved psychiatric and medical conditions, large, randomized controlled clinical trials are still needed to confirm its efficacy in the treatment of the multiple conditions for which it is often used in clinical practice.

  17. Medicalizing melancholia: exploring profiles of psychiatric professionalization.

    PubMed

    Misbach, Judith; Stam, Henderikus J

    2006-01-01

    The nineteenth century was the site of radical changes in understanding mental illness. The professionalization of psychiatry consisted primarily of the discipline's aspiration to the status of an expert medical subspecialty. While all forms of insanity were eventually reframed in medical terms, melancholia--for moral and nosological reasons--assumed a special role that made it an ideal diagnosis for conceptual reframing. Our analysis of the journal literature of the nineteenth and early twentieth centuries in North America and Germany traces several ways in which melancholia was medicalized. As the care for the insane shifted into the professional realm of physicians and medical terminology came to replace prior descriptors of mental illness, melancholia was replaced by depression. In addition, the process of delineating affective pathology assumed a distinctly medical flavor. Finally, melancholia was firmly medicalized when its boundaries blurred with neurasthenia. Differences in how ordinary affective terms became medicalized in German and North American psychiatry illustrate the importance of local historical approaches.

  18. Standards in medical record keeping.

    PubMed

    Mann, Robin; Williams, John

    2003-01-01

    Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in England and Wales. There is currently a major drive to computerise medical records across the NHS, but without improvement in the quality of paper records the full benefits of computerisation are unlikely to be realised. The onus for improving records lies with individual health professionals. Structuring the record can bring direct benefits to patients by improving patient outcomes and doctors' performance. The HIU has reviewed the literature and is developing evidence-based standards for record keeping including the structure of the record. The first draft of these standards has been released for consultation purposes. This article is the first of a series that will describe the standards, and the evidence behind them.

  19. Behavioural antecedents to pro re nata psychotropic medication administration on acute psychiatric wards.

    PubMed

    Stewart, Duncan; Robson, Deborah; Chaplin, Robert; Quirk, Alan; Bowers, Len

    2012-12-01

    This study examined the antecedents to administration of pro re nata (PRN) psychotropic medication on acute psychiatric wards, with a particular focus on its use in response to patient aggression and other conflict behaviours. A sample of 522 adult in-patients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2  weeks of admission. Two-thirds of patients received PRN medication during this period, but only 30% of administrations were preceded by patient conflict (usually aggression). Instead, it was typically administered to prevent escalation of patient behaviour and to help patients sleep. Overall, no conflict behaviours or further staff intervention occurred after 61% of PRN administrations. However, a successful outcome was less likely when medication was administered in response to patient aggression. The study concludes that improved monitoring, review procedures, training for nursing staff, and guidelines for the administration of PRN medications are needed.

  20. 42 CFR 456.170 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Medical, psychiatric, and social evaluations. 456.170 Section 456.170 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND..., and social evaluations. (a) Before admission to a mental hospital or before authorization for...

  1. Selection Factors among International Medical Graduates and Psychiatric Residency Performance

    ERIC Educational Resources Information Center

    Shiroma, Paulo R.; Alarcon, Renato D.

    2010-01-01

    Objective: The authors examine the association between the selection factors used in a psychiatric residency program and subsequent clinical and academic performance among international medical graduate (IMG) candidates. Methods: The authors completed a retrospective review of application files and residency evaluations of 50 IMG residents who…

  2. Occurrence of Medical Concerns in Psychiatric Outpatients with Intellectual Disabilities

    ERIC Educational Resources Information Center

    Azimi, Kousha; Modi, Miti; Hurlbut, Janice; Lunsky, Yona

    2016-01-01

    Despite the fact that adults with both intellectual disabilities (ID) and psychiatric disorders are at increased risk for physical health problems, few studies have described their medical concerns specifically. This study reports on the rates of physical health issues and completion of recommended health screenings among 78 adult outpatients with…

  3. Comorbidity between psychiatric and general medical disorders in homeless veterans.

    PubMed

    Goldstein, Gerald; Luther, James F; Haas, Gretchen L; Gordon, Adam J; Appelt, Cathleen

    2009-12-01

    Homeless veterans have numerous co-occurring medical and behavioral health problems. Identification of common patterns of comorbid conditions may help providers to determine severity of medical conditions and triage health care more effectively. In this study we identify such patterns of comorbid medical and psychiatric disorders using cluster analysis and we evaluate relationships between these patterns and sociodemographic factors. We used data from a survey of 3,595 veterans in a regional VA network who were presently or recently homeless assessing nine major medical disorder and six psychiatric disorder categories. Diagnostic ratings of presence or absence of these disorders were placed into the same cluster analysis to determine whether separable clusters emerged reflecting differing diagnostic profiles. There are recognizable patterns of comorbidity involving several psychiatric and general medical disorders, as well as disorders of both types that exist independently. Cluster membership was associated with various sociodemographic indices. Mental and general medical health problems in homeless veterans often occur in association with each other and form identifiable patterns that vary on sociodemographic factors.

  4. 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...

  5. 42 CFR 460.210 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 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...

  6. 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.

  7. 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...

  8. 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...

  9. 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...

  10. 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...

  11. [Challenges for the future of psychiatry and psychiatric medical care].

    PubMed

    Higuchi, Teruhiko

    2013-01-01

    In addition to the prolonged economic recession and global financial crisis, the Great East Japan Earthquake of March 2011 has caused great fear and devastation in Japan. In the midst of these, Japanese people have felt to lose the traditional values and common sense they used to share, and it has become necessary to build a new consciousness. Engaged in psychiatry and psychiatric care under these circumstances, we have to analyze the challenges we face and to brainstorm on appropriate prescriptions that can be applied to solve the problems. Five points in particular were brought up: [1] The persistently high number of suicides. [2] The increase in depression and overflowing numbers of patients visiting clinics and outpatient departments at hospitals. [3] The absolute shortage of child psychiatrists. [4] Little progress with the transition from hospitalization-centered to community-centered medical care. [5] The disappearance of beds for psychiatry patients from general hospitals. The situations surrounding these five issues were briefly analyzed and problems were pointed out. The following are five problems that psychiatry is facing: 1) A lack of large clinical trials compared to the rest of the world. 2) The drug lag and handling of global trials. 3) The lack of staff involved in education and research (in the field of psychiatry). 4) Following the DSM diagnostic criteria dogmatically, without differentiating therapeutics. 5) Other medical departments, the industry, patients, and their families are demanding objective diagnostic techniques. After analyzing the problems, and discussing to some extent what kind of prescription may be considered to solve the problems, I gave my opinion. (1) The first problem is the deep-rooted prejudice and discrimination against psychiatric disorders that continue to be present among Japanese people. The second problem is the government's policy of low remuneration (fees) for psychiatric services. The third problem, symbolic of the

  12. Psychiatric side effects of medications prescribed in internal medicine

    PubMed Central

    Casagrande Tango, Rodrigo

    2003-01-01

    Several pharmacological treatments used in internal medicine can induce psychiatric side effects (PSEs) that mimic diagnoses seen in psychiatry. PSEs may occur upon withdrawal or intoxication, and also at usual therapeutic doses. Drugs that may lead to depressive, anxious, or psychotic syndromes include corticosteroids, isotretinoin, levo-dopar mefloquine, interferon-a, and anabolic steroids, as well as some over-the-counter medications. PSEs are often difficult to diagnose and can be very harmful to patients. PSEs are discussed in this review, as well as diagnostic clues to facilitate their identification. PMID:22034468

  13. Communication Profiles of Psychiatric Residents and Attending Physicians in Medication-Management Appointments: A Quantitative Pilot Study

    ERIC Educational Resources Information Center

    Castillo, Enrico G.; Pincus, Harold A.; Wieland, Melissa; Roter, Debra; Larson, Susan; Houck, Patricia; Reynolds, Charles F.; Cruz, Mario

    2012-01-01

    Objective: The authors quantitatively examined differences in psychiatric residents' and attending physicians' communication profiles and voice tones. Methods: Audiotaped recordings of 49 resident-patient and 35 attending-patient medication-management appointments at four ambulatory sites were analyzed with the Roter Interaction Analysis System…

  14. From medicalization to hybridization: a postcolonial discourse for psychiatric nurses.

    PubMed

    Wilkin, P E

    2001-04-01

    I begin with an Orwellian dilemma [Orwell G. (1968) The Collected Essays, Journalism and Letters of George Orwell, Vol. 1, p. 239. Harcourt Brace Jovanovich, New York]: do I 'shoot the elephant' (by writing the abstract) to impress the editor? Or, with the courage of my postmodern convictions, do I lay down my rifle and disregard such suppressive editorial instructions? Bang! My words strafe the paper and the elephant is dead. How difficult it is to stay standing against the powerful currents of the dominant tradition. How easy it is to disavow the inequalities and injustices of that tradition when your livelihood (and your ego) depends upon it. So goes the theme of my paper, that, despite the clarion calls of the illustrious minority to reject the patriarchal model of medical psychiatry, psychiatric nurses continue to be propelled by the twin engines of illness and diagnosis. Yet as soon as psychiatry encounters the 'other' it becomes, in Homi K. Bhabha's words, 'hybridized': a pregnant pause created from the seeds of two different cultures. In this sense, every psychiatric moment becomes a golden opportunity for the psychiatric nurse to abdicate her role as medical factotum. Freed from these contractual obligations, she can join the 'other' and share in his experiences, sustaining rather than negating him within a truly therapeutic alliance. In similar fashion, this article has become a mixture of rhetorical fluidity and structured reality: a hybridized compromise which acknowledges the journal's publication boundaries yet still revels, at times, in the freedom of an open and lyrical text.

  15. 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...

  16. 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...

  17. 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...

  18. 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...

  19. Psychiatric drug-induced Chronic Brain Impairment (CBI): implications for long-term treatment with psychiatric medication.

    PubMed

    Breggin, Peter R

    2011-01-01

    Understanding the hazards associated with long-term exposure to psychiatric drugs is very important but rarely emphasized in the scientific literature and clinical practice. Drawing on the scientific literature and clinical experience, the author describes the syndrome of Chronic Brain Impairment (CBI) which can be caused by any trauma to the brain including Traumatic Brain Injury (TBI), electroconvulsive therapy (ECT), and long-term exposure to psychiatric medications. Knowledge of the syndrome should enable clinicians to more easily identify long-term adverse effects caused by psychiatric drugs while enabling researchers to approach the problem with a more comprehensive understanding of the common elements of brain injury as they are manifested after long-term exposure to psychiatric medications. Treatment options are also discussed.

  20. Why a shared care record is an official medical record.

    PubMed

    Gu, Yulong; Orr, Martin; Warren, Jim; Humphrey, Gayl; Day, Karen; Tibby, Sarah; Fitzpatrick, Jo

    2013-10-18

    The literature describes three categories of health records: the Official Medical Records held by healthcare providers, Personal Health Records owned by patients, and--a possible in between case--the Shared Care Record. New complications and challenges arise with electronic storage of this latter class of record; for instance, an electronic shared care record may have multiple authors, which presents challenges regarding the roles and responsibilities for record-keeping. This article discusses the definitions and implementations of official medical records, personal health records and shared care records. We also consider the case of a New Zealand pilot of developing and implementing a shared care record in the National Shared Care Planning Programme. The nature and purpose of an official medical record remains the same whether in paper or electronic form. We maintain that a shared care record is an official medical record; it is not a personal health record that is owned and controlled by patients, although it is able to be viewed and interacted with by patients. A shared care record needs to meet the same criteria for medico-legal and ethical duties in the delivery of shared care as pertain to any official medical record.

  1. Social Work Roles and Activities Regarding Psychiatric Medication: Results of a National Survey

    ERIC Educational Resources Information Center

    Bentley, Kia J.; Walsh, Joseph; Farmer, Rosemary L.

    2005-01-01

    This article reports the findings of a 2001 national survey of social workers regarding their everyday practice roles and activities regarding psychiatric medication. The results of this quantitative study indicate variability in the types of roles carried out by social workers with regard to psychiatric medication, but that perceptions of…

  2. 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...

  3. 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...

  4. 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...

  5. 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...

  6. Medical record review conduction model for improving interrater reliability of abstracting medical-related information.

    PubMed

    Engel, Lisa; Henderson, Courtney; Fergenbaum, Jennifer; Colantonio, Angela

    2009-09-01

    Medical record review (MRR) is often used in clinical research and evaluation, yet there is limited literature regarding best practices in conducting a MRR, and there are few studies reporting interrater reliability (IRR) from MRR data. The aim of this research was twofold: (a) to develop a MRR abstraction tool and standardize the MRR process and (b) to examine the IRR from MRR data. This study introduces the MRR-Conduction Model, which was used to implement a MRR, and examines the IRR between two abstractors who collected preinjury medical and psychiatric, incident-related medical and postinjury head symptom information from the medical records of 47 neurologically injured workers. Results showed that the percentage agreement was > or =85% and the unweighted kappa statistic was > or =.60 for most variables, indicating substantial IRR. An effective and reliable MRR to abstract medical-related information requires planning and time. The MRR-Conduction Model is proposed to guide the process of creating a MRR.

  7. Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies.

    PubMed

    Tucci, Veronica; Siever, Kaylin; Matorin, Anu; Moukaddam, Nidal

    2015-11-01

    Patients presenting with behavior or psychiatric complaints may have an underlying medical disorder causing or worsening their symptoms. Misdiagnosing a medical illness as psychiatric can lead to increased morbidity and mortality. A thorough history and physical examination, including mental status, are important to identify these causes and guide further testing. Laboratory and ancillary testing should be guided by what is indicated based on clinical assessment. Certain patient populations and signs and symptoms have a higher association with organic causes of behavioral complaints. Many medical problems can present with or exacerbate psychiatric symptoms, and a thorough medical assessment is imperative.

  8. Combined medical-psychiatric inpatient units: evaluation of the Centre for the Elderly.

    PubMed

    Maier, A B; Wächtler, C; Hofmann, W

    2007-08-01

    Considering the large number of elderly patients in acute hospitals who receive medical as well as psychiatric treatment because of relevant comorbidity, adequate interdisciplinary treatment models have to be developed and applied. The Centre for Elderly, a cooperation project between the departments of geriatric and psychogeriatric medicine in a community hospital in Germany, was founded in 2000. In addition to traditionally structured units, the centre consists of interdisciplinary units. Patient-, staff- and hospital-related characteristics influenced by the reformation of both departments were evaluated by comparing hospital-based registry data records containing age, gender, main and minor diagnoses, length of stay and patient transferrals within the centre. Experts working at the centre were asked to take a stand on the development of the treatment quality, allocation of patients, diagnostic procedures, consultation services and information transmission. The number of admissions to the Centre for the Elderly increased within one year. The distribution of the main diagnose groups remained unchanged, with an overlap between the geriatric and psychogeriatric department consisting of the main diagnoses dementia and depression. The length of stay and the number of transferrals decreased significantly in both departments. The majority of the interviewed employees stated that the treatment quality and the allocation of patients were improved. We conclude that interdisciplinary treatment between the departments of psychiatry and geriatric medicine may contribute to the medical needs of subgroups of elderly inpatients suffering from medical-psychiatric comorbidity.

  9. The impact of psychiatric comorbidity on Medicare reimbursement for inpatient medical care.

    PubMed

    Goldberg, R J; Daly, J; Golinger, R C

    1994-01-01

    Funding for psychiatric consultation-liaison (C-L) services has been a difficult problem. It has been suggested that the identification of psychiatric co-morbidities in Medicare patients on medical services could generate incremental hospital revenue by moving patients from a lower to a higher paying Diagnostic Related Group (DRG). This increased revenue could be used as a means of supporting the psychiatric C-L service. This study documents the financial impact of screening for and documenting psychiatric co-morbidities on a general acute medical service. We clinically assessed 100 consecutive Medicare admissions and found 25 psychiatric co-morbidities in 20 patients. In only one case did the psychiatric diagnosis result in moving the case to a higher DRG. However, the need for psychiatric consultation remains evident as there was significant lack of recognition and documentation of the psychiatric diagnoses by the medical team. The authors discuss both the financial and clinical implications of screening medical inpatients for psychiatric co-morbidities and propose directions for further studies in this area.

  10. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... medical and psychological records if that access could have an adverse affect on the mental or physical... located may afford special protection to certain medical records (e.g., drug and alcohol abuse treatment... time of the treatment or consultation was 15, 16, or 17 years old; the treatment or consultation...

  11. Medical records in equine veterinary practice.

    PubMed

    Werner, Susan H

    2009-12-01

    Quality medical records are the cornerstone of successful equine veterinary practice. The scope and integrity of the information contained in a practice's medical records influence the quality of patient care and client service and affect liability risk, practice productivity, and overall practice value.

  12. 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…

  13. Virtual Reality, Telemedicine, Web and Data Processing Innovations in Medical and Psychiatric Education and Clinical Care

    ERIC Educational Resources Information Center

    Hilty, Donald M.; Alverson, Dale C.; Alpert, Jonathan E.; Tong, Lowell; Sagduyu, Kemal; Boland, Robert J.; Mostaghimi, Arash; Leamon, Martin L.; Fidler, Don; Yellowlees, Peter M.

    2006-01-01

    Objective: This article highlights technology innovations in psychiatric and medical education, including applications from other fields. Method: The authors review the literature and poll educators and informatics faculty for novel programs relevant to psychiatric education. Results: The introduction of new technologies requires skill at…

  14. Psychiatric Comorbidity and Medication Use in Adults with Autism Spectrum Disorder

    ERIC Educational Resources Information Center

    Buck, Tara R.; Viskochil, Joseph; Farley, Megan; Coon, Hilary; McMahon, William M.; Morgan, Jubel; Bilder, Deborah A.

    2014-01-01

    The purpose of this study was to investigate comorbid psychiatric disorders and psychotropic medication use among adults with autism spectrum disorder (ASD) ascertained as children during a 1980's statewide Utah autism prevalence study (n = 129). Seventy-three individuals (56.6%) met criteria for a current psychiatric disorder; 89 participants…

  15. [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.

  16. Comparison of Methods to Assess Psychiatric Medication Adherence in Methadone-maintained Patients with Co-occurring Psychiatric Disorder

    PubMed Central

    Dunn, Kelly E.; King, Van L.; Brooner, Robert K.

    2016-01-01

    Background Adherence with psychiatric medication is a critical issue that has serious individual and public health implications. This is a secondary analysis of a large-scale clinical treatment trial of co-occurring substance use and psychiatric disorder. Method Participants (n=153) who received a clinically-indicated psychiatric medication >30 days during the 12-month study and provided corresponding data from Medication Event Monitoring System (MEMS) and Morisky Medication Taking Adherence Scale (MMAS) self-report adherence ratings were included in the analyses. Accuracy in MEMS caps openings was customized to each participant’s unique required dosing schedule. Results Consistent with expectations, MEMS-based adherence declined slowly over time, though MMAS scores of forgetting medication remained high and did not change over the 12-month study. MEMS caps openings were not significantly impacted by any baseline or treatment level variables, whereas MMAS scores were significantly associated with younger age and presence of an Axis I disorder and antisocial personality disorder, or any cluster B diagnoses. Conclusions Results suggest that MEMS caps may be a more objective method for monitoring adherence in patients with co-occurring substance use and psychiatric disorder relative to the MMAS self-report. Participants in this study were able to successfully use the MEMS caps for a 12-month period with <1% lost or broken caps, suggesting this comorbid population is able to use the MEMS successfully. Ultimately, these data suggest that an objective method for monitoring adherence in this treatment population yield more accurate outcomes relative to self-report. PMID:26851987

  17. Do Race, Ethnicity, and Psychiatric Diagnoses Matter in the Prevalence of Multiple Chronic Medical Conditions?

    PubMed Central

    Cabassa, Leopoldo J.; Humensky, Jennifer; Druss, Benjamin; Lewis-Fernández, Roberto; Gomes, Arminda P.; Wang, Shuai; Blanco, Carlos

    2013-01-01

    Background The proportion of people in the United States with multiple chronic medical conditions (MCMC) is increasing. Yet, little is known about the relationship that race, ethnicity, and psychiatric disorders have on the prevalence of MCMCs in the general population. Methods This study used data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N= 33,107). Multinomial logistic regression models adjusting for socio-demographic variables, body mass index, and quality of life were used to examine differences in the 12-month prevalence of MCMC by race/ethnicity, psychiatric diagnosis, and the interactions between race/ethnicity and psychiatric diagnosis. Results Compared to non-Hispanic Whites, Hispanics reported lower odds of MCMC and African Americans reported higher odds of MCMC after adjusting for covariates. People with psychiatric disorders reported higher odds of MCMC compared to people without psychiatric disorders. There were significant interactions between race and psychiatric diagnosis associated with rates of MCMC. In the presence of certain psychiatric disorders, the odds of MCMC were higher among African Americans with psychiatric disorders compared to non-Hispanic Whites with similar psychiatric disorders. Conclusions Our study results indicate that race, ethnicity, and psychiatric disorders are associated with the prevalence of MCMC. As the rates of MCMC rise, it is critical to identify which populations are at increased risk and how to best direct services to address their health care needs. PMID:23552429

  18. The psychoactive effects of psychiatric medication: the elephant in the room.

    PubMed

    Moncrieff, Joanna; Cohen, David; Porter, Sally

    2013-01-01

    The psychoactive effects of psychiatric medications have been obscured by the presumption that these medications have disease-specific actions. Exploiting the parallels with the psychoactive effects and uses of recreational substances helps to highlight the psychoactive properties of psychiatric medications and their impact on people with psychiatric problems. We discuss how psychoactive effects produced by different drugs prescribed in psychiatric practice might modify various disturbing and distressing symptoms, and we also consider the costs of these psychoactive effects on the mental well-being of the user. We examine the issue of dependence, and the need for support for people wishing to withdraw from psychiatric medication. We consider how the reality of psychoactive effects undermines the idea that psychiatric drugs work by targeting underlying disease processes, since psychoactive effects can themselves directly modify mental and behavioral symptoms and thus affect the results of placebo-controlled trials. These effects and their impact also raise questions about the validity and importance of modern diagnosis systems. Extensive research is needed to clarify the range of acute and longer-term mental, behavioral, and physical effects induced by psychiatric drugs, both during and after consumption and withdrawal, to enable users and prescribers to exploit their psychoactive effects judiciously in a safe and more informed manner.

  19. 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.

  20. Medical Records and Health Information Technicians

    MedlinePlus

    ... work. Although health information technicians do not provide direct patient care, they work regularly with registered nurses ... health-related occupations in which there is no direct hands-on patient care. Medical records and health ...

  1. Ethics of medical records and professional communications.

    PubMed

    Recupero, Patricia R

    2008-01-01

    In child and adolescent psychiatry, medical records and professional communications raise important ethical concerns for the treating or consulting clinician. Although a distinction may be drawn between internal records (eg, medical records and psychotherapy notes) and external communications (eg, consultation reports and correspondence with pediatricians), several ethical principles apply to both types of documentation; however, specific considerations may vary, depending upon the context in which the records or communications were produced. Special care is due with regard to thoroughness and honesty, collaboration and cooperation, autonomy and dignity of the patient, confidentiality of the patient and family members, maintaining objectivity and neutrality, electronic communications media, and professional activities (eg, political advocacy). This article reviews relevant ethical concerns for child and adolescent psychiatrists with respect to medical records and professional communications, drawing heavily from forensic and legal sources, and offers additional recommendations for further reading for clarification and direction on ethical dilemmas.

  2. 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.

  3. 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...

  4. 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 Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina...

  5. 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 Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina...

  6. 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 Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea-Spina...

  7. 38 CFR 17.905 - Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2010-07-01 2010-07-01 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-Spina Bifida and Covered Birth Defects § 17.905...

  8. Medical Services: Nursing Records and Reports

    DTIC Science & Technology

    2007-11-02

    Record—Nursing Discharge Summary) • 2–11, page 5 SF 511 (Clinical Record—Vital Signs Record) • 2–12, page 6 SF 536 (Clinical Record— Pediatric Nursing...Notes) • 2–13, page 6 SF 537 (Medical Record— Pediatric Graphic Chart) • 2–14, page 6 SF 539 (Medical Record—Abbreviated Medical Record) • 2–15, page 6...the 24–hour total of the patient’s intake and output. 2–13. SF 536 (Clinical Record— Pediatric Nursing Notes) This form may be used for pediatric

  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. Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders.

    PubMed

    Smith, Michael T; Huang, Mary I; Manber, Rachel

    2005-07-01

    Insomnia is a pervasive problem for many patients suffering from medical and psychiatric conditions. Even when the comorbid disorders are successfully treated, insomnia often fails to remit. In addition to compromising quality of life, untreated insomnia may also aggravate and complicate recovery from the comorbid disease. Cognitive behavior therapy for insomnia (CBT-I) has an established efficacy for primary insomnia, but less is known about its efficacy for insomnia occurring in the context of medical and psychiatric conditions. The purpose of this article is to present a rationale for using CBT-I in medical and psychiatric disorders, review the extant outcome literature, highlight considerations for adapting CBT-I procedures in specific populations, and suggest directions for future research. Outcome studies were identified for CBT-I in mixed medical and psychiatric conditions, cancer, chronic pain, HIV, depression, posttraumatic stress disorder, and alcoholism. Other disorders discussed include: bipolar disorder, eating disorders, generalized anxiety, and obsessive compulsive disorder. The available data demonstrate moderate to large treatment effects (Cohen's d, range=0.35-2.2) and indicate that CBT-I is a promising treatment for individuals with medical and psychiatric comorbidity. Although the literature reviewed here is limited by a paucity of randomized, controlled studies, the available data suggest that by improving sleep, CBT-I might also indirectly improve medical and psychological endpoints. This review underscores the need for future research to test the efficacy of adaptations of CBT-I to disease specific conditions and symptoms.

  11. 42 CFR 456.170 - Medical, psychiatric, and social evaluations.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... HUMAN SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental..., and social evaluations. (a) Before admission to a mental hospital or before authorization for payment... medical findings; (3) Medical history; (4) Mental and physical functional capacity; (5) Prognoses; and...

  12. Equal access for all? Access to medical information for European psychiatric trainees.

    PubMed

    Marques, João Gama; Stefanovic, Maja Pantovic; Mitkovic-Voncina, Marija; Riese, Florian; Guloksuz, Sinan; Holmes, Kevin; Kilic, Ozge; Banjac, Visnja; Palumbo, Claudia; Nawka, Alexander; Jauhar, Sameer; Andlauer, Olivier; Krupchanka, Dzmitry; da Costa, Mariana Pinto

    2016-04-30

    Access to medical information is important as lifelong scientific learning is in close relation with a better career satisfaction in psychiatry. This survey aimed to investigate how medical information sources are being used among members of the European Federation of Psychiatric Trainees. Eighty-three psychiatric trainees completed our questionnaire. A significant variation was found, and information availability levels were associated with training duration and average income. The most available sources were books and websites, but the most preferred ones were scientific journals. Our findings suggest that further steps should be taken to provide an equal access to medical information across Europe.

  13. 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

  14. Reading the medical record. I. Analysis of physicians' ways of reading the medical record.

    PubMed

    Nygren, E; Henriksson, P

    1992-01-01

    Physicians were interviewed about their routines in everyday use of the medical record. From the interviews, we conclude that the medical record is a well functioning working instrument for the experienced physician. Using the medical record as a basis for decision making involves interpretation of format, layout and other textural features of the type-written data. Interpretation of these features provides effective guidance in the process of searching, reading and assessing the relevance of different items of information in the record. It seems that this is a skill which is an integrated part of diagnostic expertise. This skill plays an important role in decision making based on the large amount of information about a patient, which is exhibited to the reader in the medical record. This finding has implications for the design of user interfaces for reading computerized medical records.

  15. Chronic medical conditions among jail detainees in residential psychiatric treatment: a latent class analysis.

    PubMed

    Swartz, James A

    2011-08-01

    Studies of incarcerates with serious mental illnesses have found elevated rates of chronic medical conditions such as asthma and diabetes, and of infectious diseases such as tuberculosis compared with general population rates. This study explored the pattern of chronic medical conditions in a sample of adult detainees in psychiatric treatment in a large urban jail to develop a clinical profile encompassing the full range of medical conditions. A total of 431 male and female detainees were sampled with certainty from admissions to a residential psychiatric treatment program (overall recruitment rate = 67%). Interviews used the World Mental Health version of the Composite International Diagnostic Interview to assess psychiatric and substance use disorders per DSM-IV criteria and chronic medical conditions. Latent class analysis was conducted using 17 medical conditions as class indicators, yielding a 3-class model composed of: a latent class with a high to intermediate probability of multiple medical conditions (HMC; 12.5% of the sample); an intermediate class with a lower probability of having a smaller number of medical conditions (MMC; 43.2%); and a class with a low probability of any medical condition (44.3%). Those in the HMC class were more likely to report respiratory problems, severe headaches, musculoskeletal pain, hypertension, and arthritis, have greater functional impairment, and have a higher number of co-occurring psychiatric disorders. Being older (50+ years) and female were associated with higher odds of being in the HMC or MMC classes. The policy implications for providing medical care to incarcerates with complex mixtures of medical conditions and psychiatric disorders are considered.

  16. Predictors of medication compliance after hospital discharge in adolescent psychiatric patients.

    PubMed

    Lloyd, A; Horan, W; Borgaro, S R; Stokes, J M; Pogge, D L; Harvey, P D

    1998-01-01

    Failure in medication compliance in adult psychiatric patients is often found to be due to side effects or associated with unawareness of illness. Little research has been conducted on medication compliance in adolescent psychiatric patients. In this study, 97 adolescent psychiatric patients, including 46 with substance abuse, were followed up an average of 14 months after their discharge from inpatient psychiatric care. Compliance with prescribed medications was examined and the association between several potential predictors and compliance was examined. The overall rate of medication compliance was only 38% at 14-month follow-up, whereas the rate of patients stopping their medications because of side effects was only 23%. Significant predictors of compliance failures were general noncompliance with the discharge plan, followed by postdischarge substance abuse. Side effects did not contribute any additional variance when these factors were considered. These data suggest that medication compliance may be adversely impacted by general tendencies toward noncompliance with treatment, which may be mediated by several possible factors. Interventions to increase awareness of the need for psychotropic medications as well as careful monitoring for substance abuse relapse in this population are suggested.

  17. Beyond emergencies: the use of physical restraints in medical and psychiatric settings.

    PubMed

    Glezer, Anna; Brendel, Rebecca Weintraub

    2010-01-01

    Physical restraints, such as locked-door seclusion and two- or four-point leather restraints, are frequently used in both the medical and psychiatric settings. Efforts are currently under way to reduce the use of physical restraints in psychiatric settings; various institutional, state, and federal policies are place. However, using these same restraints in the context of providing medical care for psychiatric patients is more complicated, as it is uncertain which principles and regulations apply in a particular setting. For example, is the restraint governed by the policies that regulate the psychiatric application of restraints, by those that regulate the medical application of restraints, or by both? This article reviews the principles and regulations governing the use of restraints on psychiatric patients, with specific attention to the use of restraints in providing medical treatment to that patient population. Also addressed are general principles of risk management to help avoid negative outcomes and to reduce the risk of litigation for unauthorized or unlawful restraint. A case example is used to illustrate these concepts.

  18. Improving capacity and consent to treatment recording in psychiatric inpatient wards: A multi-centre quality improvement project

    PubMed Central

    Li, Ching; Stellman, Judith; Patel, Nitisha; Dalton, Florence

    2016-01-01

    Assessment of mental capacity provides an ethical and legal framework for care which values patients' autonomy whilst recognising the instances where it is appropriate to act in patients' best interests. Existing medical literature indicates that mental capacity is poorly documented in psychiatric inpatient settings. The aim of the project was to examine the frequency of capacity and consent to treatment documentation with a view to creating changes in practice by raising awareness about the importance of assessing and documenting mental capacity. A multi-centre quality improvement project was conducted in September 2014 across all general adult psychiatric inpatient wards in the North Central London Training Scheme. The frequency of documentation of capacity and consent to treatment for all adult psychiatric inpatient wards across North Central London was measured. Electronic patient notes were audited retrospectively to ascertain whether capacity and consent to treatment on admission, and within the preceding seven days of data collection, was recorded. Data was collected across three successive time points during a 12 month period following the implementation of changes. A total of 232 patients were included in the baseline measurements. The results highlighted a deficiency in the recording of capacity and consent to treatment for adult psychiatric inpatients. The results showed that, of the patients audited, 49.8% had their capacity and consent to treatment assessed on admission, 61.9% had a capacity assessment in the previous 7 days and 60.5% had consent recorded in the previous 7 days. These findings were presented at local hospital teaching sessions at each of the audited sites. These sessions also gave teaching on mental capacity. Audit cycle 1 was conducted 6 months later, this included 213 patients and showed a 30% improvement in the frequency of documentation across all measures. The results showed that 77% of patients audited had their capacity and

  19. Improving capacity and consent to treatment recording in psychiatric inpatient wards: A multi-centre quality improvement project.

    PubMed

    Li, Ching; Stellman, Judith; Patel, Nitisha; Dalton, Florence

    2016-01-01

    Assessment of mental capacity provides an ethical and legal framework for care which values patients' autonomy whilst recognising the instances where it is appropriate to act in patients' best interests. Existing medical literature indicates that mental capacity is poorly documented in psychiatric inpatient settings. The aim of the project was to examine the frequency of capacity and consent to treatment documentation with a view to creating changes in practice by raising awareness about the importance of assessing and documenting mental capacity. A multi-centre quality improvement project was conducted in September 2014 across all general adult psychiatric inpatient wards in the North Central London Training Scheme. The frequency of documentation of capacity and consent to treatment for all adult psychiatric inpatient wards across North Central London was measured. Electronic patient notes were audited retrospectively to ascertain whether capacity and consent to treatment on admission, and within the preceding seven days of data collection, was recorded. Data was collected across three successive time points during a 12 month period following the implementation of changes. A total of 232 patients were included in the baseline measurements. The results highlighted a deficiency in the recording of capacity and consent to treatment for adult psychiatric inpatients. The results showed that, of the patients audited, 49.8% had their capacity and consent to treatment assessed on admission, 61.9% had a capacity assessment in the previous 7 days and 60.5% had consent recorded in the previous 7 days. These findings were presented at local hospital teaching sessions at each of the audited sites. These sessions also gave teaching on mental capacity. Audit cycle 1 was conducted 6 months later, this included 213 patients and showed a 30% improvement in the frequency of documentation across all measures. The results showed that 77% of patients audited had their capacity and

  20. 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 Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...) Authentication must include signatures or a secured computer entry by a unique identifier of the primary...

  1. 32 CFR 701.122 - Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... have an adverse effect on the mental or physical health of the individual. Normally, this determination... THE NAVY DOCUMENTS AFFECTING THE PUBLIC DON Privacy Program § 701.122 Medical records. (a) Health... health information established by HIPAA. (2) DOD Directive 6025.18-R prescribes the uses and...

  2. Auditing medical records helps reduce liability.

    PubMed

    Ganguli, G; Winfrey, S

    1990-10-01

    An internal audit of a hospital's medical records department compares the department to standards developed by the hospital and to benchmarks set by accrediting organizations. An auditor can review the department's economy and effectiveness through employee surveys, direct observation, and interviews. By uncovering deficiencies and making recommendations for their correction, an internal audit can help limit a hospital's liability exposure.

  3. 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 Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROTECTION OF... maintained by the Food and Drug Administration. (b) The Food and Drug Administration may apply the...

  4. 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 Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROTECTION OF... maintained by the Food and Drug Administration. (b) The Food and Drug Administration may apply the...

  5. [Nurse's coworking to electronic medical record].

    PubMed

    Maresca, M; Gavaciuto, D; Cappelli, G

    2007-01-01

    Nephrologists need to register and look at a great number of clinical data. The use of electronic medical records may improve efficiency and reduce errors. Aim of our work is to report the experience of Villa Scassi Hospital in Genoa, where a "patient file" has been performed to improve nephrology practice management. The file contains all clinical records, laboratory and radiology data, therapy, dialysis clinics, in addition to reports of out-patients department. This system allowed a better efficiency in diagnosis and treatment of the patient. Moreover experience of nurses in employing electronic medical records is reported. A reduced number of errors was found in therapy administering, because of a only one data source for physicians and nurses.

  6. 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...

  7. 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... 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...

  8. Factors influencing adherence to psychopharmacological medications in psychiatric patients: a structural equation modeling approach

    PubMed Central

    De las Cuevas, Carlos; de Leon, Jose; Peñate, Wenceslao; Betancort, Moisés

    2017-01-01

    Purpose To evaluate pathways through which sociodemographic, clinical, attitudinal, and perceived health control variables impact psychiatric patients’ adherence to psychopharmacological medications. Method A sample of 966 consecutive psychiatric outpatients was studied. The variables were sociodemographic (age, gender, and education), clinical (diagnoses, drug treatment, and treatment duration), attitudinal (attitudes toward psychopharmacological medication and preferences regarding participation in decision-making), perception of control over health (health locus of control, self-efficacy, and psychological reactance), and level of adherence to psychopharmacological medications. Structural equation modeling was applied to examine the nonstraightforward relationships and the interactive effects among the analyzed variables. Results Structural equation modeling demonstrated that psychiatric patients’ treatment adherence was associated: 1) negatively with cognitive psychological reactance (adherence decreased as cognitive psychological reactance increased), 2) positively with patients’ trust in their psychiatrists (doctors’ subscale), 3) negatively with patients’ belief that they are in control of their mental health and that their mental health depends on their own actions (internal subscale), and 4) positively (although weakly) with age. Self-efficacy indirectly influenced treatment adherence through internal health locus of control. Conclusion This study provides support for the hypothesis that perceived health control variables play a relevant role in psychiatric patients’ adherence to psychopharmacological medications. The findings highlight the importance of considering prospective studies of patients’ psychological reactance and health locus of control as they may be clinically relevant factors contributing to adherence to psychopharmacological medications.

  9. MATERNAL DEPRESSIVE SYMPTOMS, DEPRESSION AND PSYCHIATRIC MEDICATION USE IN RELATION TO RISK OF PRETERM DELIVERY

    PubMed Central

    Gavin, Amelia R.; Holzman, Claudia; Siefert, Kristine; Tian, Yan

    2009-01-01

    Purpose This study examined associations among maternal depression, measured in several ways, psychiatric medication use in pregnancy, and preterm delivery (PTD). Methods Data were from 3,019 women enrolled in the Pregnancy Outcomes and Community Health Study (1998–2004), a prospective study of pregnant women in five Michigan communities. Information on depressive symptoms, history of depression and psychiatric medication use was ascertained through interviews at mid-pregnancy. These variables and other relevant covariates were incorporated into regression models with a binary outcome, i.e., term (≥ 37 weeks’ gestation) as referent and PTD (< 37 weeks’ gestation). A second set of models used a multi-category outcome, i.e., term as referent and PTD further subdivided by gestational weeks and clinical circumstances. Main Findings The odds of overall PTD was increased among women who used psychiatric medication during pregnancy and had either elevated levels of depressive symptoms at mid-pregnancy (adjusted odds ratio [AOR] = 2.0 [95% CI 1.1, 3.6]) or a history of depression prior to pregnancy (AOR= 1.6 [95% CI 1.1, 2.5]). The combination of psychiatric medication use in pregnancy and depression, prior to pregnancy or within pregnancy, was most strongly linked to a medically indicated delivery at < 35 weeks’ gestation (AOR 2.9 and 3.6 respectively). Conclusions There are at least two plausible explanations for these findings. First, psychiatric medication use in pregnancy may pose an excess risk of PTD. Second, medication use may be an indicator of depressive symptom severity, which is a direct or indirect (i.e., alters behavior) contributing factor to PTD. PMID:19733802

  10. 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…

  11. 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.

  12. 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

  13. Examining the Impact of Psychiatric Diagnosis and Comorbidity on the Medical Lethality of Adolescent "Suicide Attempts"

    ERIC Educational Resources Information Center

    Mc Manama O'Brien, Kimberly H.; Berzin, Stephanie C.

    2012-01-01

    Specific psychiatric diagnoses and comorbidity patterns were examined to determine if they were related to the medical lethality of "suicide attempts" among adolescents presenting to an urban general hospital (N = 375). Bivariate analysis showed that attempters with substance abuse disorders had higher levels of lethality than attempters without…

  14. Adolescent Attitudes toward Psychiatric Medication: The Utility of the Drug Attitude Inventory

    ERIC Educational Resources Information Center

    Townsend, Lisa; Floersch, Jerry; Findling, Robert L.

    2009-01-01

    Background: Despite the effectiveness of psychotropic treatment for alleviating symptoms of psychiatric disorders, youth adherence to psychotropic medication regimens is low. Adolescent adherence rates range from 10-80% (Swanson, 2003; Cromer & Tarnowski, 1989; Lloyd et al., 1998; Brown, Borden, and Clingerman, 1985; Sleator, 1985) depending on…

  15. Antipsychotic Medication Prescription Patterns in Adults with Developmental Disabilities Who Have Experienced Psychiatric Crisis

    ERIC Educational Resources Information Center

    Lunsky, Yona; Elserafi, Jonny

    2012-01-01

    Antipsychotic medication rates are high in adults with developmental disability. This study considered rates of antipsychotic use in 743 adults with developmental disability who had experienced a psychiatric crisis. Nearly half (49%) of these adults were prescribed antipsychotics. Polypharmacy was common with 22% of those prescribed antipsychotics…

  16. The Right of Psychiatric Patients to Refuse Medication: Where Should Social Workers Stand?

    ERIC Educational Resources Information Center

    Bentley, Kia J.

    1993-01-01

    Addresses differences among competence, commitment, and mental illness; the right to privacy; and the prohibition against cruel and unusual punishment. Reviews professional motivations in relation to both sides of controversy over rights of psychiatric patients to refuse medication. Presents position for social work profession that stands for…

  17. Evaluation of treatment effects in obese children with co-morbid medical or psychiatric conditions

    Technology Transfer Automated Retrieval System (TEKTRAN)

    The need for effective treatments for pediatric overweight is well known. We evaluated the applicability of an evidence-based treatment in an applied clinic setting that includes children with severe obesity and comorbid medical or psychiatric conditions. Forty-eight overweight children and their fa...

  18. Access to Medical and Exposure Records

    DTIC Science & Technology

    2001-01-01

    Access to Medical and Exposure Records U.S. Department of Labor Occupational Safety and Health Administration OSHA 3110 2001 (Revised) U.S...Department of Labor Elaine L. Chao, Secretary Occupational Safety and Health Administration John L. Henshaw, Assistant Secretary This booklet provides a...standards and the Occupational Safety and Health Act. Because interpretations and enforcement policy may change over time, the best sources for

  19. Electronic medical records in clinical teaching.

    PubMed

    Warboys, Ina; Mok, Wai Yin; Frith, Karen H

    2014-01-01

    The purpose of the project was to provide students with experiences to develop their technology competency and examine student perceptions about an academic electronic medical record (EMR) as a learning tool. Nurse educators need to integrate EMRs into their curricula to give students practice in the use of electronic documentation and retrieval of clinical information. The findings of this study indicated that students' use of EMRs at least 5 times resulted in the development of positive perceptions about their EMR experience.

  20. Computer Assisted Medical Record Documentation-Hyperalimentation

    PubMed Central

    Guritz, Gary A.; Brier, Kenneth Leo; Buth, Jonathan A.

    1985-01-01

    A microcomputer total parenteral nutrition (TPN) (hyperalimentation) program was developed to provide individualized intravenous nutritional support. The microcomputer TPN program assisted in preliminary nutritional assessment and enabled the pharmacist to manipulate different solutions in achieving a final product. Computerized calculations are based on caloric needs, nitrogen requirements and solutions available. The resultant program allowed greater clinical involvement by the pharmacist and enabled complete medical record documentation of the nutritional regimen.

  1. [Electronic medical record--interface specifications with medical informatics systems].

    PubMed

    Mocanu, Carmen; Mocanu, Mihai

    2007-01-01

    The paper presents the initial efforts of description and implementation for a new scheme of electronic patients recording, based on distributed database for chronic ophthalmologic diseases. Structural specifications derived from principal system's goals are the implementation of an efficient and flexible way of patients' data administration, using actual Web technologies, permitting future extensions, without reducing in performances and without exponential cost increasing. A very important aspect, that must be take into consideration is their interfacing with other medical programs and systems, as the systems for recording clinical data, monitoring systems (Patient Administrations Systems - PAS) for demographical data, systems for monitoring of treatment (Hippocrates program), web systems, including wireless.

  2. 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. ... 12 Banks and Banking 4 2011-01-01 2011-01-01 false Special procedures: Medical records....

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

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 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. ... 12 Banks and Banking 5 2012-01-01 2012-01-01 false Special procedures: Medical records....

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

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 4 2010-01-01 2010-01-01 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...

  5. Psychiatric disorders and selected variables among medical students in Belgrade (Yugoslavia).

    PubMed

    Erić, L; Radovanović, Z; Jevremović, I; Marinković, J

    1988-01-01

    The mental health of a group of 523 medical freshmen (97% of the respective population) was assessed 1 month after enrollment. Students with psychiatric impairment (84 or 16.1%) were compared with those assessed to be mentally healthy in respect of a number of variables. Cluster, correlation, and principal component analyses revealed that psychiatric disorders were related to the result of the screening test, in a lesser degree to the test anxiety, and not at all to any of the other tested variables (separation from parents, family completeness, education of parents, number of siblings, number of employees in the family, grade point average in high school, and smoking).

  6. [Social and medical characteristics of psychiatric patients admitted by the district physician].

    PubMed

    Rogoll, H; Späte, H F

    1984-03-01

    The medical and social backgrounds of the 323 patients admitted to the County Psychiatric and Neurological Hospital Bernburg by committal order (Art. 6 of the Committment Act of the GDR) are analyzed. During these nine years such committals accounted for between 3.1 and 6.5% of all psychiatric admissions. The most frequent causes were schizophrenia (55.1%), alcohol addiction (10.5%) and geropsychiatric disorders (9.3%). Only 2% of the 323 patients concerned were committed indefinitely by court order after the initial six week term had expired. The study establishes the humanitarian nature of the Committal Act and the success of its practical application.

  7. 28 CFR 549.43 - Involuntary psychiatric treatment and medication.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... treatment for the mental illness and less restrictive alternatives (e.g., seclusion or physical restraint... institution mental health division administrator shall appoint a staff representative. Witnesses should be called if they have information relevant to the inmate's mental condition and/or need for medication,...

  8. 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...

  9. 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...

  10. 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...

  11. 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...

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

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 3 2010-01-01 2010-01-01 false Special procedures for medical records. 261a.7... Requests by Individual to Whom Record Pertains § 261a.7 Special procedures for medical records. Medical or psychological records requested pursuant to § 261a.5 of this part shall be disclosed directly to the...

  15. 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...

  16. Optimizing medication use with a pharmacist-provided comprehensive medication management service for patients with psychiatric disorders.

    PubMed

    Cobb, Carla D

    2014-12-01

    Our objective was to evaluate a pharmacist-delivered comprehensive medication management (CMM) service provided to patients with psychiatric disorders. We conducted a retrospective review and analysis of medication-related data, and a return on investment cost analysis. The project consisted of 154 patients with psychiatric disorders who were referred to the CMM service by physicians, therapists, case managers, friends, or family, and were seen by the service between April 2011 and July 2013. CMM evaluates a patient's medications to ensure that they are appropriate, effective, safe, and convenient. Patients were seen by pharmacists trained in CMM and the treatment of mental illnesses, including one board-certified psychiatric pharmacist. All medications were reviewed including prescriptions, over-the-counter medications, and nutritional supplements. The patients' medication-related concerns, goals of treatment, vital signs, and laboratory studies were reviewed. Drug therapy problems such as adverse reactions, unnecessary medications, excessive doses, and poor medication adherence were identified, and written recommendations were mailed to patients and physicians within 1 week. Patients were offered follow-up in 4-6 weeks and were seen as many times as needed to resolve drug therapy problems. The 154 patients completed 256 CMM visits. A mean of 10.1 medical and psychiatric conditions and 13.7 medications/person were assessed. A mean of 5.6 drug therapy problems/patient were identified. A total net cost savings was estimated to be $90,484.00, with a mean savings of $586.55/patient. The cost of providing the service was estimated at $32,185.93. The return on investment was estimated to be 2.8; thus for every dollar spent on providing the service, $2.80 was estimated to be saved. Patients with mental illnesses may benefit from pharmacist-delivered CMM to help resolve drug therapy problems. Medication management may improve clinical outcomes and reduce costs. In

  17. The computerized medical record in action.

    PubMed

    Meyer, C R

    1994-08-01

    Before the advent of the IPS computerized medical record at Burlington, Zallen did not own a computer. Although he learned touch-typing in high school, he emphatically states that he hated it. The average age of the physicians on staff at Burlington is about 40, but few had extensive previous experience with computers. According to Zallen, all have adapted to the CPR with few tears or tirades. The physicians continue to "tweak" the system to customize their own scrapbook and templates. Lahey physicians who work at Burlington part time are using the system, although with more staff help. The CPR is alive and well at Burlington Health Center. HCHP physicians can and do use computers in their daily work, producing quality medical records that are readable and retrievable. Nonetheless, promises that computers will make records more complete and accessible and will improve quality measurement will be mere blather if the CPR doesn't make users' lives easier. My last question to Zallen was "How has this system made your life harder?" After one pensive second, he replied, "I really can't think of anything." To me, that is potent testimony that the CPR is not a techie's fantasy, but rather, a pragmatic, workable answer to the needs of 21st century medicine.

  18. 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....

  19. Psychiatric and medical management of marijuana intoxication in the emergency department.

    PubMed

    Bui, Quan M; Simpson, Scott; Nordstrom, Kimberly

    2015-05-01

    We use a case report to describe the acute psychiatric and medical management of marijuana intoxication in the emergency setting. A 34-year-old woman presented with erratic, disruptive behavior and psychotic symptoms after recreational ingestion of edible cannabis. She was also found to have mild hypokalemia and QT interval prolongation. Psychiatric management of cannabis psychosis involves symptomatic treatment and maintenance of safety during detoxification. Acute medical complications of marijuana use are primarily cardiovascular and respiratory in nature; electrolyte and electrocardiogram monitoring is indicated. This patient's psychosis, hypokalemia and prolonged QTc interval resolved over two days with supportive treatment and minimal intervention in the emergency department. Patients with cannabis psychosis are at risk for further psychotic sequelae. Emergency providers may reduce this risk through appropriate diagnosis, acute treatment, and referral for outpatient care.

  20. Psychiatric and Medical Management of Marijuana Intoxication in the Emergency Department

    PubMed Central

    Bui, Quan M.; Simpson, Scott; Nordstrom, Kimberly

    2015-01-01

    We use a case report to describe the acute psychiatric and medical management of marijuana intoxication in the emergency setting. A 34-year-old woman presented with erratic, disruptive behavior and psychotic symptoms after recreational ingestion of edible cannabis. She was also found to have mild hypokalemia and QT interval prolongation. Psychiatric management of cannabis psychosis involves symptomatic treatment and maintenance of safety during detoxification. Acute medical complications of marijuana use are primarily cardiovascular and respiratory in nature; electrolyte and electrocardiogram monitoring is indicated. This patient’s psychosis, hypokalemia and prolonged QTc interval resolved over two days with supportive treatment and minimal intervention in the emergency department. Patients with cannabis psychosis are at risk for further psychotic sequelae. Emergency providers may reduce this risk through appropriate diagnosis, acute treatment, and referral for outpatient care. PMID:25987916

  1. 38 CFR 46.6 - Medical quality assurance records confidentiality.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 2 2010-07-01 2010-07-01 false Medical quality assurance records confidentiality. 46.6 Section 46.6 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS... Medical quality assurance records confidentiality. Note that medical quality assurance records that...

  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, 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...

  4. 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...

  5. 10 CFR 35.2080 - Records of mobile medical services.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 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...

  6. 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...

  7. 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...

  8. 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...

  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. 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...

  11. 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...

  12. Personal health records as portal to the electronic medical record.

    PubMed

    Cahill, Jennifer E; Gilbert, Mark R; Armstrong, Terri S

    2014-03-01

    This topic review discusses the evolving clinical challenges associated with the implementation of electronic personal health records (PHR) that are fully integrated with electronic medical records (EMR). The benefits of facilitating patient access to the EMR through web-based, PHR-portals may be substantial; foremost is the potential to enhance the flow of information between patient and healthcare practitioner. The benefits of improved communication and transparency of care are presumed to be a reduction in clinical errors, increased quality of care, better patient-management of disease, and better disease and symptom comprehension. Yet PHR databases allow patients open access to newly-acquired clinical data without the benefit of concurrent expert clinical interpretation, and therefore may create the potential for greater patient distress and uncertainty. With specific attention to neuro-oncology patients, this review focuses on the developing conflicts and consequences associated with the use of a PHR that parallels data acquisition of the EMR in real-time. We conclude with a discussion of recommendations for implementing fully-integrated PHR for neuro-oncology patients.

  13. 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…

  14. [The psychiatric criticism of social prejudices as a medical strategy of legitimation].

    PubMed

    Möller, Torger

    2006-01-01

    The subject of this article is the relation between psychiatric knowledge and social prejudice. This will be observed from the perspective of the medical discourse and the perspective of the history of science in a case study on epilepsy. In context of an increasing democratization of science and society a discussion on the social discrimination of epileptic patients entered the medical discourse in the 1960s and 70s. In the medical discourse the cause for discrimination is ascribed to emotionally determined prejudices found in the population, that are to be countered by educating the population with scientific knowledge. From the perspective of the history of science it however becomes apparent, that the prejudices found in the population are a result of a popularization of psychiatric knowledge beginning in the end of the 19th and reaching well into the 20th century. Thus, it is science and not the population that is the source of these so called prejudices. In the closing remarks these findings are discussed as different 'discourse' strategies for the legitimation of psychiatry and psychiatric objects.

  15. 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... magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  16. 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... magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  17. 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 870.2800 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES... magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  18. 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... magnetic tape recorder. (a) Identification. A medical magnetic tape recorder is a device used to record...

  19. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and...

  20. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and...

  1. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and...

  2. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and...

  3. 10 CFR 712.38 - Maintenance of medical records.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ...). (b) The psychological record of HRP candidates and HRP-certified individuals is a component of the medical record. The psychological record must: (1) Contain any clinical reports, test protocols and...

  4. Long-Term Psychiatric and Medical Consequences of Anabolic-Androgenic Steroid Abuse

    PubMed Central

    Kanayama, Gen; Hudson, James I.; Pope, Harrison G.

    2008-01-01

    Background The problem of anabolic-androgenic steroid (AAS) abuse has recently generated widespread public and media attention. Most AAS abusers, however, are not elite athletes like those portrayed in the media, and many are not competitive athletes at all. This larger but less visible population of ordinary AAS users began to emerge in about 1980. The senior members of this population are now entering middle age; they represent the leading wave of a new type of aging former substance abusers, with specific medical and psychiatric risks. Methods We reviewed the evolving literature on long-term psychiatric and medical consequences of AAS abuse. Results Long-term use of supraphysiologic doses of AAS may cause irreversible cardiovascular toxicity, especially atherosclerotic effects and cardiomyopathy. In other organ systems, evidence of persistent toxicity is more modest, and interestingly, there is little evidence for an increased risk of prostate cancer. High concentrations of AAS, comparable to those likely sustained by many AAS abusers, produce apoptotic effects on various cell types, including neuronal cells - raising the specter of possibly irreversible neuropsychiatric toxicity. Finally, AAS abuse appears to be associated with a range of potentially prolonged psychiatric effects, including dependence syndromes, mood syndromes, and progression to other forms of substance abuse. However, the prevalence and severity of these various effects remains poorly understood. Conclusions As the first large wave of former AAS users now moves into middle age, it will be important to obtain more systematic data on the long-term psychiatric and medical consequences of this form of substance abuse. PMID:18599224

  5. Recorded interviews with human and medical geneticists.

    PubMed

    Harper, Peter S

    2017-02-01

    A series of 100 recorded interviews with human and medical geneticists has been carried out and some general results are reported here. Twenty countries across the world are represented, mostly European, with a particular emphasis on the United Kingdom. A priority was given to older workers, many of whom were key founders of human genetics in their own countries and areas of work, and over 20 of whom are now no longer living. The interviews also give valuable information on the previous generation of workers, as teachers and mentors of the interviewees, thus extending the coverage of human genetics back to the 1930s or even earlier. A number of prominent themes emerge from the interview series; notably the beginnings of human cytogenetics from the late 1950s, the development of medical genetics research and its clinical applications in the 1960s and 1970s, and more recently the beginnings and rapid growth of human molecular genetics. The interviews provide vivid personal portraits of those involved, and also show the effects of social and political issues, notably those arising from World War 2 and its aftermath, which affected not only the individuals involved but also broader developments in human genetics, such as research related to risks of irradiation. While this series has made a start in the oral history of this important field, extension and further development of the work is urgently needed to give a fuller picture of how human genetics has developed.

  6. Anonymization of Longitudinal Electronic Medical Records

    PubMed Central

    Tamersoy, Acar; Loukides, Grigorios; Nergiz, Mehmet Ercan; Saygin, Yucel; Malin, Bradley

    2013-01-01

    Electronic medical record (EMR) systems have enabled healthcare providers to collect detailed patient information from the primary care domain. At the same time, longitudinal data from EMRs are increasingly combined with biorepositories to generate personalized clinical decision support protocols. Emerging policies encourage investigators to disseminate such data in a deidentified form for reuse and collaboration, but organizations are hesitant to do so because they fear such actions will jeopardize patient privacy. In particular, there are concerns that residual demographic and clinical features could be exploited for reidentification purposes. Various approaches have been developed to anonymize clinical data, but they neglect temporal information and are, thus, insufficient for emerging biomedical research paradigms. This paper proposes a novel approach to share patient-specific longitudinal data that offers robust privacy guarantees, while preserving data utility for many biomedical investigations. Our approach aggregates temporal and diagnostic information using heuristics inspired from sequence alignment and clustering methods. We demonstrate that the proposed approach can generate anonymized data that permit effective biomedical analysis using several patient cohorts derived from the EMR system of the Vanderbilt University Medical Center. PMID:22287248

  7. Patterns of psychotropic medication use in inpatient and outpatient psychiatric settings in Saudi Arabia

    PubMed Central

    Alosaimi, Fahad D; Alhabbad, Abdulhadi; Abalhassan, Mohammed F; Fallata, Ebtihaj O; Alzain, Nasser M; Alassiry, Mohammad Zayed; Haddad, Bander Abdullah

    2016-01-01

    Objective To study the pattern of psychotropic medication use and compare this pattern between inpatient and outpatient psychiatric settings in Saudi Arabia. Method This cross-sectional observational study was conducted between July 2012 and June 2014 on patients seeking psychiatric advice at major hospitals in five main regions of Saudi Arabia. Male (n=651) and female (n=594) patients who signed the informed consent form and were currently or had been previously using psychotropic medications, irrespective of the patient’s type of psychiatric diagnosis and duration of the disease, were included. A total of 1,246 patients were found to be suitable in the inclusion criteria of whom 464 were inpatients while 782 were outpatients. Results Several studied demographic factors have shown that compared with outpatients, inpatients were more likely to be male (P=0.004), unmarried (P<0.001), have less number of children (1–3; P=0.002), unemployed (P=0.001), have a lower family income (<3,000 SR; P<0.001), live in rural communities (P<0.001), have a lower body mass index (P=0.001), and are smokers (P<0.001); however, there were no differences with regard to age or educational levels. The current frequency of use of psychotropic medications in overall patients was antipsychotics (76.6%), antidepressants (41.4%), mood stabilizers (27.9%), and antianxiety (6.2%). However, compared to outpatients, the current use of medications for inpatients was more frequent (93.8% vs 89.9%, P=0.019) with inpatients more likely to be treated with multiple medications (2.1 vs 1.8 medications). A similar trend was observed in the case of antipsychotics, high potency first-generation antipsychotics, second-generation antipsychotics, mood stabilizers, and antianxiety medicines where inpatients were more frequently treated with these medications for all psychiatric diagnoses when compared with outpatients. On the contrary, in the case of antidepressant treatment, an opposite trend was observed

  8. Social Media Use in Psychiatric Graduate Medical Education: Where We Are and the Places We Could Go.

    PubMed

    O'Hagan, Thomas S; Roy, Durga; Anton, Blair; Chisolm, Margaret S

    2016-02-01

    This commentary discusses the use of social media in psychiatric graduate medical education (GME) based on a systematic search of the literature. The authors conclude that research on social media use in psychiatric GME is in its infancy. For the most part, the few articles that have been published on this topic caution against the use of social media in psychiatric training. However, reports from other specialties, in which social media use in medical education has been more extensively studied, suggest that there may be significant benefits to incorporating social media into medical education. Although additional challenges may exist in implementing these tools in psychiatric education, the authors suggest that this is an emerging field of scholarship that merits further investigation.

  9. 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...

  10. 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...

  11. 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... instrument used to make the survey, and the name of the individual who performed the survey....

  12. The use of psychiatric medications to treat depressive disorders in African American women.

    PubMed

    Jackson, Allesa P

    2006-07-01

    Review of the current literature confirms that African American women as a group are underdiagnosed and undertreated for psychiatric disorders. Hence, much effort is targeted towards awareness, screening, and improving access to health care for this population. However, once an African American woman is diagnosed with a major mental health disorder, determining the optimal course of treatment is a process that must be approached carefully because of gender and racial/ethnic differences in response and metabolism of psychiatric medications. African American women fall into both of these understudied categories. Given the small numbers of African American women represented in the clinical trials on which clinical practice is based, one must consider the limitations of current knowledge regarding psychoactive medications in this population. Culturally based attitudes or resistance to pharmacotherapy can complicate the use of psychoactive medicines, often a first-line approach in primary care clinics. Communication with patients is key, as well as openness to patient concerns and tolerance of these medications.

  13. 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

  14. Privacy Impact Assessment for the Wellness Program Medical Records

    EPA Pesticide Factsheets

    The Wellness Program Medical Records System collects contact information and other Personally Identifiable Information (PII). Learn how this data is collected, used, accessed, the purpose of data collection, and record retention policies.

  15. Auditory and visual P300 event related potentials are not altered in medically and psychiatrically normal chronic marihuana users.

    PubMed

    Patrick, G; Straumanis, J J; Struve, F A; Nixon, F; Fitz-Gerald, M J; Manno, J E; Soucair, M

    1995-01-01

    Attempts to use Event Related Potentials, particularly the cognitive or P300 evoked potential, as measures of CNS effects of THC use have been infrequent and have produced inconsistent results. We published a pilot study in which psychiatric patient THC users had significantly prolonged auditory P300 latencies and reduced amplitudes as contrasted with non-users. Because psychiatric diagnoses and medication effects could not be controlled, we repeated the study with medically and psychiatrically normal subjects selected with extremely stringent exclusion criteria and screening procedures. P300 latency differences between THC users and controls were not detected. Using all subjects, THC users displayed reduced auditory and visual P300 amplitudes. However, when age differences between THC users and controls were removed, all significant P300 amplitude differences were removed as well. The contaminating effect of using psychiatric patients in THC research is discussed and the importance of using carefully screened normal subjects in studies of neurophysiological abuse drug effects is stressed.

  16. Examining the impact of psychiatric diagnosis and comorbidity on the medical lethality of adolescent suicide attempts.

    PubMed

    McManama O'Brien, Kimberly H; Berzin, Stephanie C

    2012-08-01

    Specific psychiatric diagnoses and comorbidity patterns were examined to determine if they were related to the medical lethality of suicide attempts among adolescents presenting to an urban general hospital (N=375). Bivariate analysis showed that attempters with substance abuse disorders had higher levels of lethality than attempters without substance abuse. Regression results indicated having depression comorbid with any other diagnosis was not associated with medical lethality. However, having a substance abuse disorder was associated with higher suicide attempt lethality, highlighting the importance of substance abuse as a risk factor for lethal suicide attempts in adolescents. This finding stimulates critical thinking around the understanding of suicidal behavior in youth and the development and implementation of treatment strategies for suicidal adolescents with substance abuse disorders.

  17. 'There's the record, closed and final': Rough for Theatre II as Psychiatric Encounter.

    PubMed

    Heron, Jonathan; Broome, Matthew

    2016-06-01

    A co-authored collaboration between a theatre practitioner and a clinical psychiatrist, this paper will examine Rough for Theatre II (RFTII) and Beckett's demonstration of the way records are used to understand the human subject. Using Beckett's play to explore interdisciplinary issues of embodiment and diagnosis, the authors will present a dialogue that makes use of the 'best sources' in precisely the same manner as the play's protagonists. One of those sources will be Beckett himself, as Heron will locate the play in its theatrical context through reflections upon his own practice (with Fail Better Productions, UK) as well as recent studies such as Beckett, Technology and the Body (Maude 2009) and Performing Embodiment in Samuel Beckett's Drama (McMullan 2010); another source will be the philosopher Wilhelm Windleband, whose 1901 History of Philosophy was read and noted upon by Beckett in the 1930s, as Broome will introduce a philosophical and psychiatric context to the exchange. Windelband is now a neglected figure in philosophy; but as one of the key figures of Neo-Kantianism in the late 19(th) century, his work was an important impetus to that of Rickert, Weber and Heidegger. Specifically, Windelband gives us the distinction between idiographic and nomothetic understanding of individuals, an approach that is of relevance to the psychiatric encounter. This academic dialogue will consider tensions between subjectivity and objectivity in clinical and performance practice, while examining Beckett's analysis of the use of case notes and relating them back to Windelband's ideas on the understanding of others. The dialogue took place in 2011 at the University of Warwick, and has since been edited by the authors.

  18. Integrated IMR for Psychiatric and General Medical Illness for Adults Aged 50 or Older With Serious Mental Illness

    PubMed Central

    Bartels, Stephen J.; Pratt, Sarah I.; Mueser, Kim T.; Naslund, John A.; Wolfe, Rosemarie S.; Santos, Meghan; Xie, Haiyi; Riera, Erik G.

    2016-01-01

    Objectives Self-management is promoted as a strategy for improving outcomes for serious mental illness as well as for chronic general medical conditions. This study evaluated the feasibility and effectiveness of an eight-month program combining training in self-management for both psychiatric and general medical illness, including embedded nurse care management. Methods Participants were 71 middle-aged and older adults (mean age=60.3±6.5) with serious mental illness and chronic general medical conditions who were randomly assigned to receive integrated Illness Management and Recovery (I-IMR) (N=36) or usual care (N=35). Feasibility was determined by attendance at I-IMR and nurse sessions. Effectiveness outcomes were measured two and six months after the intervention (ten- and 14-month follow-ups) and included self-management of psychiatric and general medical illness, participation in psychiatric and general medical encounters, and self-reported acute health care utilization. Results I-IMR participants attended 15.8±9.5 I-IMR and 8.2±5.9 nurse sessions, with 75% attending at least ten I-IMR and five nurse sessions. Compared with usual care, I-IMR was associated with greater improvements in participant and clinician ratings for psychiatric illness self-management, greater diabetes self-management, and an increased preference for detailed diagnosis and treatment information during primary care encounters. The proportion of I-IMR participants with at least one psychiatric or general medical hospitalization decreased significantly between baseline and ten- and 14-month follow-ups. Conclusions I-IMR is a feasible intervention for this at-risk group and demonstrated potential effectiveness by improving self-management of psychiatric illness and diabetes and by reducing the proportion of participants requiring psychi atric or general medical hospitalizations. PMID:24292559

  19. Implementation of an Electronic Medical Records System

    DTIC Science & Technology

    2008-05-07

    their patients and their previous medical history. Capitalizing on progress made in the informational technology realm, which include more...example, medication and allergy list, problem list and past medical and family/ social history); • Building the descriptive tags for a lab or radiology...clinical trials. Arch Fam Med. 1996; 5: 271-278. 14. Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic review of

  20. 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...

  1. 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...

  2. 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...

  3. 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…

  4. 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...

  5. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 18 Conservation of Power and Water Resources 2 2012-04-01 2012-04-01 false Special procedures-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...

  6. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 18 Conservation of Power and Water Resources 2 2013-04-01 2012-04-01 true Special procedures-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...

  7. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 18 Conservation of Power and Water Resources 2 2014-04-01 2014-04-01 false Special procedures-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...

  8. 18 CFR 1301.16 - Special procedures-medical records.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 18 Conservation of Power and Water Resources 2 2011-04-01 2011-04-01 false Special procedures-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...

  9. 37 CFR 102.26 - Special procedures: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... routine use, for all systems of records containing medical records, consultations with an individual's... them; (3) Obtain specific, written consent for USPTO to consult the individual's physician and/or... be warranted, USPTO's medical expert shall so consult or transmit. Whether or not such a...

  10. Computerized medical records: defining a standard without the computer.

    PubMed

    Bradbury, A R

    1991-01-01

    The inevitable computerization of medical records may be a boon or a hindrance to the practice of medicine. A comprehensive view of the project is essential for its success. Definite goals for the computerized medical record are stated to this end. An argument is presented for keeping the structure of the medical record separate from any specific requirements of technology. An elegant structure for medical records is proposed, independent of any computer system and requiring a minimum of definitions or special characters. The roles of clinical specialists (such as physicians and nurses), medical records specialists, administrators, accountants, and computer architects (hardware and software) are defined. In particular, the tasks of lexicon and template creation are defined and emphasized as urgent and ongoing challenges for specialty organizations.

  11. [Audit: medical record documentation among advanced cancer patients].

    PubMed

    Perceau, Elise; Chirac, Anne; Rhondali, Wadih; Ruer, Murielle; Chabloz, Claire; Filbet, Marilène

    2014-02-01

    Medical record documentation of cancer inpatients is a core component of continuity of care. The main goal of the study was an assessment of medical record documentation in a palliative care unit (PCU) using a targeted clinical audit based on deceased inpatients' charts. Stage 1 (2010): a clinical audit of medical record documentation assessed by a list of items (diagnosis, prognosis, treatment, power of attorney directive, advance directives). Stage 2 (2011): corrective measures. Stage 3 (2012): re-assessment with the same items' list after six month. Forty cases were investigated during stage 1 and 3. After the corrective measures, inpatient's medical record documentation was significantly improved, including for diagnosis (P = 0.01), diseases extension and treatment (P < 0.001). Our results highlighted the persistence of a weak rate of medical record documentation for advanced directives (P = 0.145).

  12. 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...

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

    Code of Federal Regulations, 2012 CFR

    2012-04-01

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

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 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...

  15. 18 CFR 701.306 - Special procedure: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 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...

  16. Privacy Act System of Records: Medical and Research Study Records of Human Volunteers, EPA-34

    EPA Pesticide Factsheets

    Learn about the Medical and Research Study Records of Human Volunteers System, including who is covered in the system, the purpose of data collection, routine uses for the system's records, and other security procedures.

  17. Crystal methamphetamine, its analogues, and HIV infection: medical and psychiatric aspects of a new epidemic.

    PubMed

    Urbina, Antonio; Jones, Kristina

    2004-03-15

    The use of the recreational drug crystal methamphetamine among younger homosexual men is expanding, and with it, unsafe sex behaviors that increase the transmission of human immunodeficiency virus (HIV). This article reviews available literature on the medical and psychiatric morbidities associated with methamphetamine abuse in HIV-infected patients. Medical complications include hypertension, hyperthermia, rhabdoymyolysis, and stroke. One fatal case of ingestion of methamphetamine with HIV medication has been documented. Two fatal cases of ingestion of HIV medication with the amphetamine analogue n-methyl-3,4 methylenedioxymethamphetamine (MDMA, or "ecstasy") have also been reported. Some molecular researchers suggest that dopaminergic systems are vulnerable to the combined neurotoxicity of HIV infection and methamphetamine. Population surveys indicate high rates of HIV infection among methamphetamine abusers and high rates of unprotected anal intercourse during drug intoxication. Intoxication can sometimes produce paranoia, auditory hallucinations, and, occasionally, violent behavior. Amphetamine withdrawal commonly results in symptoms of depression. Methamphetamine is a new challenge related to treatment and prevention of HIV infection.

  18. Electronic health records and online medical records: an asset or a liability under current conditions?

    PubMed

    Allen-Graham, Judith; Mitchell, Lauren; Heriot, Natalie; Armani, Roksana; Langton, David; Levinson, Michele; Young, Alan; Smith, Julian A; Kotsimbos, Tom; Wilson, John W

    2017-01-20

    Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information.Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital's current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary.Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution.Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services.What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This

  19. Attitudes and experience of youth and their parents with psychiatric medication and relationship to self-reported adherence.

    PubMed

    O'Brien, Megan; Crickard, Elizabeth; Lee, Jaehoon; Holmes, Cheryl

    2013-10-01

    Few studies have directly examined the interrelationship of teen and parent attitudes toward psychiatric medication and how this relates to medication adherence. In the current study, survey data from 19 parent-child dyads were analyzed to investigate the relationship of parent and teen attitudes toward medication, decision self-efficacy, and current involvement in decisions about psychiatric medication with self-reported adherence. Structural equation modeling techniques were used to fit actor-partner interdependence models to examine bidirectional effects of the dyadic relationships. Teens and parents had similarly positive attitudes toward medication, high levels of self-efficacy and self-reported adherence. Current involvement in decisions about medications was significantly lower for teens compared to their parents. The actor-partner interdependence models revealed that parent levels of decision self-efficacy were related to youth self-reported adherence (partner effect). Youth attitudes toward medications were related to youth self-reported adherence (actor effect). Parent and teen actor effects of decisional self-efficacy were significantly associated with current involvement. Providers need to be aware of the importance of engaging both teens and parents in decisions about psychiatric medication and recognize the need to explicitly elicit questions and concerns from young patients.

  20. Neurasthenia, Generalized Anxiety Disorder, and the Medicalization of Worry in a Vietnamese Psychiatric Hospital.

    PubMed

    Tran, Allen L

    2016-04-26

    This article examines two forms of the medicalization of worry in an outpatient psychiatric clinic in Ho Chi Minh City, Vietnam. Biomedical psychiatrists understand patients' symptoms as manifestations of the excessive worry associated with generalized anxiety disorder (GAD). Drawing on an ethnopsychology of emotion that reflects increasingly popular models of neoliberal selfhood, these psychiatrists encourage patients to frame psychic distress in terms of private feelings to address the conditions in their lives that lead to chronic anxiety. However, most patients attribute their symptoms to neurasthenia instead of GAD. Differences between doctors' and patients' explanatory models are not just rooted in their understandings of illness but also in their respective conceptualizations of worry in terms of emotion and sentiment. Patients with neurasthenia reject doctors' attempts to psychologize distress and maintain a model of worry that supports a sense of moral selfhood based on notions of obligation and sacrifice.

  1. [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.

  2. HIV-infected individuals with co-occurring bipolar disorder evidence poor antiretroviral and psychiatric medication adherence.

    PubMed

    Moore, David J; Posada, Carolina; Parikh, Mili; Arce, Miguel; Vaida, Florin; Riggs, Patricia K; Gouaux, Ben; Ellis, Ronald J; Letendre, Scott L; Grant, Igor; Atkinson, J Hampton

    2012-11-01

    The contribution of bipolar disorder (BD), a prevalent serious mental illness characterized by impulsivity and mood instability, to antiretroviral (ART) and psychiatric medication adherence among HIV-infected (HIV+) individuals is unknown. We examined medication adherence among 44 HIV+/BD+ persons as compared to 33 demographically- and medically-comparable HIV+/BD- persons. Classification of adherent (≥ 90%) or non-adherent (<90%) based on proportion of correctly taken doses over 30 days was determined using electronic medication monitoring devices. HIV+/BD+ persons were significantly less likely to be ART adherent (47.7%) as compared to HIV+/BD- (90.9%) persons. Within the HIV+/BD+ group, mean psychiatric medication adherence was significantly worse than ART medication adherence, although there was a significant correlation between ART and psychiatric adherence levels. Importantly, 30-day ART adherence was associated with plasma virologic response among HIV+/BD+ individuals. Given the high overlap of HIV and BD, and the observed medication adherence difficulties for these persons, specialized adherence improvement interventions are needed.

  3. HIV-infected individuals with co-occurring bipolar disorder evidence poor antiretroviral and psychiatric medication adherence

    PubMed Central

    Moore, David J.; Posada, Carolina; Parikh, Mili; Arce, Miguel; Vaida, Florin; Riggs, Patricia K.; Gouaux, Ben; Ellis, Ronald J.; Letendre, Scott L.; Grant, Igor; Atkinson, J. Hampton

    2012-01-01

    The contribution of bipolar disorder (BD), a prevalent serious mental illness characterized by impulsivity and mood instability, to antiretroviral (ART) and psychiatric medication adherence among HIV-infected (HIV+) individuals is unknown. We examined medication adherence among 44 HIV+/BD+ persons as compared to 33 demographically- and medically-comparable HIV+/BD− persons. Classification of adherent (≥90%) or non-adherent (<90%) based on proportion of correctly taken doses over 30 days was determined using electronic medication monitoring devices. HIV+/BD+ persons were significantly less likely to be ART adherent (47.7%) as compared to HIV+/BD− (90.9%) persons. Within the HIV+/BD+ group, mean psychiatric medication adherence was significantly worse than ART medication adherence, although there was a significant correlation between ART and psychiatric adherence levels. Importantly, 30-day ART adherence was associated with plasma virologic response among HIV+/BD+ individuals. Given the high overlap of HIV and BD, and the observed medication adherence difficulties for these persons, specialized adherence improvement interventions are needed. PMID:22041931

  4. Autonomic nervous system dysfunction in psychiatric disorders and the impact of psychotropic medications: a systematic review and meta-analysis

    PubMed Central

    Alvares, Gail A.; Quintana, Daniel S.; Hickie, Ian B.; Guastella, Adam J.

    2016-01-01

    Background Autonomic nervous system (ANS) dysfunction is a putative underlying mechanism for increased cardiovascular disease risk in individuals with psychiatric disorders. Previous studies suggest that this risk may be related to psychotropic medication use. In the present study we systematically reviewed and analyzed published studies of heart rate variability (HRV), measuring ANS output, to determine the effect of psychiatric illness and medication use. Methods We searched for studies comparing HRV in physically healthy adults with a diagnosed psychiatric disorder to controls and comparing HRV pre- and post-treatment with a psychotropic medication. Results In total, 140 case–control (mood, anxiety, psychosis, dependent disorders, k = 151) and 30 treatment (antidepressants, antipsychotics; k = 43) studies were included. We found that HRV was reduced in all patient groups compared to controls (Hedges g = −0.583) with a large effect for psychotic disorders (Hedges g = −0.948). Effect sizes remained highly significant for medication-free patients compared to controls across all disorders. Smaller and significant reductions in HRV were observed for specific antidepressants and antipsychotics. Limitations Study quality significantly moderated effect sizes in case–control analyses, underscoring the importance of assessing methodological quality when interpreting HRV findings. Conclusion Combined findings confirm substantial reductions in HRV across psychiatric disorders, and these effects remained significant even in medication-free individuals. Reductions in HRV may therefore represent a significant mechanism contributing to elevated cardiovascular risk in individuals with psychiatric disorders. The negative impact of specific medications on HRV suggest increased risk for cardiovascular disease in these groups, highlighting a need for treatment providers to consider modifiable cardiovascular risk factors to attenuate this risk. PMID:26447819

  5. Behaviour Management Problems as Predictors of Psychotropic Medication and Use of Psychiatric Services in Adults with Autism

    ERIC Educational Resources Information Center

    Tsakanikos, Elias; Costello, Helen; Holt, Geraldine; Sturmey, Peter; Bouras, Nick

    2007-01-01

    We examined behaviour management problems as predictors of psychotropic medication, use of psychiatric consultation and in-patient admission in a group of 66 adults with pervasive developmental disorder (PDD) and intellectual disability (ID) and 99 controls matched in age, gender and level of ID. Overall, people with PDD had higher rates of most…

  6. 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

  7. SOAP to SNOCAMP: improving the medical record format.

    PubMed

    Larimore, W L; Jordan, E V

    1995-10-01

    Not since the development of the SOAP note in the problem-oriented medical record has there been a significant need to alter the format of medical record documentation. With the intrusion of third-party audits, malpractice attorney subpoenas, medical guidelines, and reimbursement code criteria into the practice of medicine, there is a need to expand the traditional SOAP note. This article proposes a new acronym, "SNOCAMP," for medical record documentation. SNOCAMP retains the SOAP format, which includes subjective, objective, assessment, and plan of treatment, with the addition of nature of the presenting complaint, counseling, and medical decision-making. It is hoped that this new, more explicit format will prove successful in meeting the divergent needs of practicing physicians, the patients they serve, and the inquiring minds that look over their shoulders.

  8. 44 CFR 6.31 - Special requirements for medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... and probable outcome, the system manager shall not release the medical information to the subject... 44 Emergency Management and Assistance 1 2010-10-01 2010-10-01 false Special requirements for medical records. 6.31 Section 6.31 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT...

  9. Design elements of a telemedical medical record.

    PubMed Central

    Adelhard, K.; Eckel, R.; Hölzel, D.; Tretter, W.

    1996-01-01

    Computerized Patient Records are becoming telemedical and multimedia documents. They should accompany the patients their whole lifetime and collect data from many different sites. Special requirements are arising to fulfill these demands. A prototype of such a system was designed and implemented at the university hospital in Grosshadern, Germany to show its feasibility, discuss the design elements and demonstrate its capabilities. A Flexible data model, interpretable contents, open communication structures and physical compilation are the cornerstones of this approach that allows communication via Internet or Smart cards. PMID:8947711

  10. Current research on the epidemiology, medical and psychiatric effects, and treatment of methamphetamine use

    PubMed Central

    Rawson, Richard A.

    2014-01-01

    Methamphetamine (MA) is a drug that is widely used in many parts of the world. It has multiple neurobiological impacts on the nervous system, some of which are transitory and some more long lasting. MA activates the reward system of the brain and produces effects that are highly reinforcing, which can lead to abuse and dependence. Routes of administration that produce rapid onset of the drug’s effects (i.e., smoking and injection) are likely to lead to more rapid addiction and more medical and psychiatric effects. The medical effects of MA use are extensive, and chronic use of MA can produce significant neurological damage as well as damage to cardiovascular, pulmonary, and other organ systems. Both acute and chronic MA use can lead to extreme paranoia, anxiety, and depression, and following discontinuation of MA use, cognitive deficits and anhedonia can persist for months. No effective pharmacotherapies have been developed for the treatment of MA dependence, although this is an area of very active research. Several behavioral treatments have been shown to reduce MA use, but better treatments are needed. The research agenda for MA is substantial, with development of effective pharmacotherapies as one of the most important priorities. PMID:25214749

  11. Current Research on Methamphetamine: Epidemiology, Medical and Psychiatric Effects, Treatment, and Harm Reduction Efforts

    PubMed Central

    Radfar, Seyed Ramin; Rawson, Richard A.

    2014-01-01

    Background Methamphetamine (MA) which is known as “shisheh” in Iran is a drug that widely is used in many parts of the world and it is near to a decade that is available for the most drug users and has a considerable prevalence of use. Due to high abuse prevalence and very new challenging phenomenon, it is very important that researchers and treatment providers become more familiar with different aspects of MA. Discussion It has multiple neurobiological impacts on the nervous system, some of which are transitory and some longer lasting. MA activates the reward system of the brain and produces effects that are highly reinforcing, which can lead to abuse and dependence. Routes of administration that produce rapid onset of the drug’s effects (i.e., smoking and injection) are likely to lead to more rapid addiction and more medical and psychiatric effects. No effective pharmacotherapies have been developed for the treatment of MA dependence; although, this is an area of very active research. Several behavioral treatments have been shown to reduce MA use, but better treatments are needed. Conclusion Harm reduction strategies for non-treatment seeking MA users are needed to reduce the risk of human immunodeficiency virus and other medical risks. The research agenda for MA is substantial, with development of effective pharmacotherapies as one of the most important priorities. Appropriate and effective response for prevention, treatment and harm reduction services due to increasing problems regarding MA in Iran and some other countries in the region. PMID:25984282

  12. The electronic patient records of the Hannover Medical School.

    PubMed

    Porth, A J; Niehoff, C; Matthies, H K

    1999-01-01

    In this paper, the successful introduction of a commercially available electronic patient record archiving system at the Hannover Medical School is described. Since 1996, more than 11 million document sheets of 130,000 patient records have been stored electronically. Currently, 100,000 sheets are stored each week.

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

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 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...

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

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 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...

  15. 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...

  16. 12 CFR 1102.104 - Special procedure: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 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...

  17. 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...

  18. Privacy, confidentiality, privilege, and the medical record. Part I.

    PubMed

    Hoyt, E M

    1986-08-01

    For thousands of years physicians have recorded clinical observations as private notes to document the clinical course, findings, and treatment of their patients. The medical record was generated exclusively for the physician's use in treating the patient. Physicians and hospitals are now under extraordinary pressure to reveal patient information. During the past 20 years, the role of the medical record has changed and it now has become a multipurpose document. Health care records are the topic of reports, interviews and depositions. Controlled disclosure of the sensitive information contained in the record is essential in today's society yet, when such information is released, various considerations must be carefully evaluated and weighed. From his vantage point as a physician and attorney, the author shares his insight and his concerns about privacy, confidentiality and privilege as related to health records in this two part article.

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

    PubMed

    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.

  20. 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,…

  1. 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…

  2. $\\mathtt {Deepr}$: A Convolutional Net for Medical Records.

    PubMed

    Nguyen, Phuoc; Tran, Truyen; Wickramasinghe, Nilmini; Venkatesh, Svetha

    2017-01-01

    Feature engineering remains a major bottleneck when creating predictive systems from electronic medical records. At present, an important missing element is detecting predictive regular clinical motifs from irregular episodic records. We present Deepr (short for Deep record), a new end-to-end deep learning system that learns to extract features from medical records and predicts future risk automatically. Deepr transforms a record into a sequence of discrete elements separated by coded time gaps and hospital transfers. On top of the sequence is a convolutional neural net that detects and combines predictive local clinical motifs to stratify the risk. Deepr permits transparent inspection and visualization of its inner working. We validate Deepr on hospital data to predict unplanned readmission after discharge. Deepr achieves superior accuracy compared to traditional techniques, detects meaningful clinical motifs, and uncovers the underlying structure of the disease and intervention space.

  3. Neighborhood linking social capital as a predictor of psychiatric medication prescription in the elderly: a Swedish national cohort study

    PubMed Central

    Sundquist, Jan; Hamano, Tsuyoshi; Li, Xinjun; Kawakami, Naomi; Shiwaku, Kuninori; Sundquist, Kristina

    2014-01-01

    Objectives Little is known about the association between neighborhood linking social capital and psychiatric medication in the elderly. The present study analyzes whether there is an association between linking social capital (a theoretical concept describing the amount of trust between individuals and societal institutions) and prescription of antipsychotics, anxiolytics, hypnotics/sedatives, antidepressants, or anti-dementia drugs. Design, Setting, Participants and Measurements The entire Swedish population aged 65+, a total of 1,292,816 individuals, were followed from 1 July 2005 until first prescription of psychiatric medication, death, emigration, or the end of the study on 31 December 2010. Small geographic units were used to define neighborhoods. The definition of linking social capital was based on mean voting participation in each neighborhood unit, categorized in three groups. Multilevel logistic regression was used to estimate odds ratios (ORs) and between-neighborhood variance in three different models. Results There was an inverse association between the level of linking social capital and prescription of psychiatric medications (except for anti-dementia drugs). The associations decreased, but remained significant, after accounting for age, sex, family income, marital status, country of birth, and education level (except for antidepressants). The OR for prescription of antipsychotics in the crude model was 1.65 (95% CI 1.53–1.78) and decreased, but remained significant (OR = 1.26; 95% CI 1.17–1.35), after adjustment for the individual-level sociodemographic variables. Conclusions Decision-makers should take into account the potentially negative effect of linking social capital on psychiatric disorders when planning sites of primary care centers and psychiatric clinics, as well as other kinds of community support for elderly patients with such disorders. PMID:24831853

  4. Ethnic differences in the effectiveness of cognitive behavioral therapy combined with medication: Comparing Asian American and white psychiatric patients.

    PubMed

    Tang, Jennifer Y; Li, Chieh; Rodgers, Rachel F; Ballou, Mary

    2016-12-01

    Several meta-analyses have demonstrated the effectiveness of treatment utilizing cognitive behavioral therapy (CBT) combined with medication. There is, however, a paucity of research comparing the effectiveness of this combined treatment with psychiatric patients from different ethnic backgrounds. This study is the first of its kind to compare the effectiveness of CBT combined with medication for Asian American and White patients' psychiatric symptom severity levels of depression, anxiety, psychological well-being, and quality of life. The study examined the effects of CBT combined with medication for 43 Asian American and 43 White Non-Hispanic patients at an acute psychiatric partial hospital. A 2×2 between-within repeated measures analysis of variance was used. Results indicated significant improvement after treatment in all symptom categories assessed for the Asian American and White patients. The findings displayed trends over the course of treatment toward a greater decrease in anxiety symptoms among Asian patients but a larger increase in functioning level among White patients. In conclusion, the findings from this study provide preliminary cross-cultural support for CBT combined with medication as a treatment in partial hospital settings and suggest that the effectiveness of such treatments is similar across cultural groups.

  5. Considering Governance for Patient Access to E-Medical Records.

    PubMed

    Day, Karen; Wells, Susan

    2015-01-01

    People having access to their medical records could have a transformative improvement effect on healthcare delivery and use. Our research aimed to explore the concerns and attitudes of giving people electronic access to their medical records through patient portals. We conducted 28 semi-structured interviews with 30 people, asking questions about portal design, organisational implications and governance. We report the findings of the governance considerations raised during the interviews. These revealed that (1) there is uncertainty about the possible design and extent of giving people access to their medical records to view/use, (2) existing policies about patient authentication, proxy, and privacy require modification, and (3) existing governance structures and functions require further examination and adjustment. Future research should include more input from patients and health informaticians.

  6. 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

  7. 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.

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

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 28 Judicial Administration 2 2010-07-01 2010-07-01 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. Alcohol Misuse among College Athletes: Self-Medication for Psychiatric Symptoms?

    ERIC Educational Resources Information Center

    Miller, B. E.; Miller, M. N.; Verhegge, R.; Linville, H. H.; Pumariega, A. J.

    2002-01-01

    Surveys a collegiate athlete population for alcohol abuse as well as self-reported depression, anxiety, and other psychiatric symptoms. Significant correlations were found between reported alcohol abuse and self-reported symptoms of depression and general psychiatric symptoms. Findings suggest a possible link between psychopathology and serious…

  10. A model for critiquing based on automated medical records.

    PubMed

    van der Lei, J; Musen, M A

    1991-08-01

    We describe the design of a critiquing system, HyperCritic, that relies on automated medical records for its data input. The purpose of the system is to advise general practitioners who are treating patients who have hypertension. HyperCritic has access to the data stored in a primary-care information system that supports a fully automated medical record. Hyper-Critic relies on data in the automated medical record to critique the management of hypertensive patients, avoiding a consultation-style interaction with the user. The first step in the critiquing process involves the interpretation of the medical record in an attempt to discover the physician's actions and decisions. After detecting the relevant events in the medical record, HyperCritic views the task of critiquing as the assignment of critiquing statements to these patient-specific events. Critiquing statements are defined as recommendations involving one or more suggestions for possible modifications in the actions of the physician. The core of the model underlying HyperCritic is that the process of generating the critiquing statements is viewed as the application of a limited set of abstract critiquing tasks. We distinguish four categories of critiquing tasks: preparation tasks, selection tasks, monitoring tasks, and responding tasks. The execution of these critiquing tasks requires specific medical factual knowledge. This factual knowledge is separated from the critiquing tasks and is stored in a medical fact base. The principal advantage demonstrated by HyperCritic is the adaption of a domain-independent critiquing structure. We show how this domain-independent critiquing structure can be used to facilitate knowledge acquisition and maintenance of the system.

  11. Topographic quantitative EEG sequelae of chronic marihuana use: a replication using medically and psychiatrically screened normal subjects.

    PubMed

    Struve, F A; Straumanis, J J; Patrick, G; Leavitt, J; Manno, J E; Manno, B R

    1999-10-01

    In two previous studies it was reported that chronic marihuana (THC) use was associated with unique quantitative EEG features which were present in the non-intoxicated state. THC users, as contrasted with controls, had significant elevations of Absolute Power, Relative Power, and Coherence of alpha activity over the bilateral frontal cortex. Furthermore, a quantitative EEG discriminant function analyses permitted a 95% correct user versus non-user classification. However, because all of the THC users and 58% of the non-user controls were psychiatric inpatients, diagnostic and medication effects, if any, were uncontrolled. In the present study the same quantitative EEG methods were used to study daily THC users and non-user controls who underwent a rigorous screening process to insure that they were medically and psychiatrically healthy. The results of previous studies were replicated and an additional EEG correlate of chronic THC exposure (reduced alpha frequency) was identified.

  12. Early and middle latency evoked potentials in medically and psychiatrically normal daily marihuana users: a paucity of significant findings.

    PubMed

    Patrick, G; Straumanis, J J; Struve, F A; Fitz-Gerald, M J; Manno, J E

    1997-01-01

    The use of evoked potentials to study CNS effects of marihuana (THC) have produced inconsistent findings. Our previous pilot studies suggested that auditory P300 latencies and amplitudes, auditory P50 and somatosensory P30 amplitudes and brainstem auditory evoked potential latencies were altered in THC users. Because these findings were flawed by uncontrolled psychiatric diagnostic and medication variables, we undertook a controlled investigation of screened medically and psychiatrically normal THC users and controls. When age effects were controlled, THC related alterations of brain stem and both auditory and visual P300 responses could not be seen. This report extends our analyses to other auditory, somatosensory and visual evoked potentials. With the possible exception of an elevated auditory P50 amplitude, significant evoked potential correlates to daily THC use were not seen when normals were studied and age effects controlled.

  13. [Three new records of medical plant in Hubei, China].

    PubMed

    Li, Hou-Cong; Yuan, De-Pei; Liu, Yuan

    2014-07-01

    In order to have a better understanding of the species diversity of medical plants in Enshi, Hubei of China, extensive field investigations and specimen collections were conducted in Enshi and adjacent regions. Based on field observations of plants in their living habitats and comparative morphological studies on specimens in herbarium of Hubei minzu University and other available herbaria as well, three new records of medical plants in Hubei, Scutellaria yunnanensis, Alangium faberi var. heterophyllum, and Drymaria diandra, were reported in this paper.

  14. Assessment of impact of pharmacophilia and pharmacophobia on medication adherence in patients with psychiatric disorders: A cross-sectional study

    PubMed Central

    Christudas, Mini Johnson; Gupta, Balaji Sathyanarayana; Undela, Krishna; Isaac, Noel M.; Ram, Dushad; Ramesh, Madhan

    2016-01-01

    Aims: To investigate the impact of pharmacophilia and pharmacophobia on medication adherence among patients with psychiatric disorders. Materials and Methods: A cross-sectional, observational study was conducted in the Department of Psychiatry over a period of 2 months. Patients above 18 years of age with a psychiatric diagnosis as per the International Classification of Diseases 10 and receiving at least one psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) for >1 month were enrolled in the study. Patients who were critically ill, on magico-religious treatment (beliefs prevalent in a particular culture concerning various supernatural influences operating in the environment), diagnosis of dementia, or mental retardation and patients from whom reliable history of illness cannot be obtained were excluded from the study. Drug attitude inventory scale was used to classify patients into pharmacophilic and pharmacophobic groups. Medication adherence rating scale was used to identify the extent of medication adherence. Results: Among 176 patients included, 110 were found to be pharmacophilic and 54 were pharmacophobic. The number of hospitalizations (P < 0.03) and adverse drug reactions (P < 0.001) were found to be higher in pharmacophobic group as compared to pharmacophilic group. Antipsychotics were found to be most commonly prescribed medications among pharmacophobic group (P < 0.001). In this study, patients who had pharmacophilia were found to be have higher adherence score (mean score: 6.98) than patients with pharmacophobia (mean score: 2.9), with P< 0.001. Conclusions: This study concluded that pharmacophobia toward psychopharmacological agents can significantly reduce the medication adherence among patients with psychiatric disorders. PMID:28066110

  15. A hypermedia-based medical records management system.

    PubMed

    Laforest, F; Frénot, S; Flory, A

    1998-01-01

    This article presents a new way to manage computerized medical records, based on a totally-hypermedia system. As a matter of fact, the classical use of a database limits the necessary variability of the medical record, in function of both the patient profile and the care practitioner habits. The system we propose is based on a hospital Intranet, and on the XML language. This language allows the definition of semantic tags in hyperdocuments, and thus information retrieval is ensured through semantic tags indexation.

  16. Customer-oriented medical records can promote patient satisfaction.

    PubMed

    MacStravic, R S

    1988-04-01

    The customer-oriented medical record helps promote patient satisfaction by providing a mechanism to monitor and document quality of care from the patient's perspective. Information that should be contained in the record includes the following: Personal and family information. Reasons for selecting the provider. Reasons for patient visit. Patient requests and responses thereto. Provider and staff observations. Patient feedback. Summaries of previous visits. Record of progress made. In addition to promoting patient satisfaction, the customer-oriented medical record provides a data base for analyzing the current market that can be used in designing marketing communications to attract new patients. It also contributes to provider success by reminding care givers of their commitment to patient satisfaction, motivating them to be sensitive to patients' needs and expectations, and helping them to personalize the care experience.

  17. [Definition of the core area of medical services in the psychiatric-psychotherapeutic field--the prerequisite for any delegation].

    PubMed

    Jordan, Wolfgang; Bleich, Stefan; Cohrs, Stefan; von Einsiedel, Regina; Falkai, Peter; Grosskopf, Volker; Hauth, Iris; Steiner, Johann; Adler, Lothar

    2011-11-01

    Based on legal jurisdiction, knowledge of the psychiatric-psychotherapeutic field and insight into the necessity of a new allocation of responsibilities in the overall therapeutic service of a clinic, the core areas of medical activities are defined for the first time, innovative organisational approaches to the reorganisation of therapeutic service are presented and discussed against the background of qualified staff deficit, introduction of an OPS coding for inpatient psychiatry and economic constraints.

  18. 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.

  19. [Security specifications for electronic medical records on the Internet].

    PubMed

    Mocanu, Mihai; Mocanu, Carmen

    2007-01-01

    The extension for the Web applications of the Electronic Medical Record seems both interesting and promising. Correlated with the expansion of Internet in our country, it allows the interconnection of physicians of different specialties and their collaboration for better treatment of patients. In this respect, the ophthalmologic medical applications consider the increased possibilities for monitoring chronic ocular diseases and for the identification of some elements for early diagnosis and risk factors supervision. We emphasize in this survey some possible solutions to the problems of interconnecting medical information systems to the Internet: the achievement of interoperability within medical organizations through the use of open standards, the automated input and processing for ocular imaging, the use of data reduction techniques in order to increase the speed of image retrieval in large databases, and, last but not least, the resolution of security and confidentiality problems in medical databases.

  20. Navy Mental Health Information System (NAMHIS): A Psychiatric Application of COSTAR (Computer Stored Ambulatory Record).

    DTIC Science & Technology

    1984-03-01

    Statististical Manual of Mental Disorders published by the American Psychiatric Association (DSM-III) 7 All of the DSM-III diagnoses have been added to...1 2 3 Eating Disorder HBA - 1 2 3 Homicidal Behavior SID -12 3 Slop Disorder MON -12 3 Moodiness SXP - 1 2 3 Sexual Problem NRV - 1 2 3 Nervousness... Sleepwalking Phobias Bedwetting Running away from home Tantrums Juvenile arrests Hyperactivity Juvenile detentions Nightmares Delinquency Coments: SCHOOL

  1. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Condition: Medical records. 494.170 Section 494.170 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE...

  2. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Condition: Medical records. 494.170 Section 494.170 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE...

  3. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 5 2012-10-01 2012-10-01 false Condition: Medical records. 494.170 Section 494.170 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE...

  4. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 5 2014-10-01 2014-10-01 false Condition: Medical records. 494.170 Section 494.170 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE...

  5. 42 CFR 494.170 - Condition: Medical records.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Condition: Medical records. 494.170 Section 494.170 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE...

  6. Who owns the information in the medical record? Copyright issues.

    PubMed

    Mair, Judith

    2011-01-01

    As part of every private healthcare practice and healthcare facility, documentation of patients' healthcare, diagnoses and treatment are an ongoing requirement with legal connotations. The question that may arise is whether copyright can subsist in patient medical records, and if so, what benefit may arise from ownership of such copyright.

  7. 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…

  8. 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…

  9. Sharing electronic medical records across multiple heterogeneous and competing institutions.

    PubMed Central

    Kohane, I. S.; van Wingerde, F. J.; Fackler, J. C.; Cimino, C.; Kilbridge, P.; Murphy, S.; Chueh, H.; Rind, D.; Safran, C.; Barnett, O.; Szolovits, P.

    1996-01-01

    Most early reports of implemented World-Wide Web (W3) medical record systems describe single institution architectures. We describe W3-EMRS, a multi-institutional architecture, and its implementation. Thorny problems in data sharing underlined by the W3-EMRS project are reviewed. PMID:8947738

  10. 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:...

  11. 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:...

  12. Performance analysis of a medical record exchanges model.

    PubMed

    Huang, Ean-Wen; Liou, Der-Ming

    2007-03-01

    Electronic medical record exchange among hospitals can provide more information for physician diagnosis and reduce costs from duplicate examinations. In this paper, we proposed and implemented a medical record exchange model. According to our study, exchange interface servers (EISs) are designed for hospitals to manage the information communication through the intra and interhospital networks linked with a medical records database. An index service center can be given responsibility for managing the EIS and publishing the addresses and public keys. The prototype system has been implemented to generate, parse, and transfer the health level seven query messages. Moreover, the system can encrypt and decrypt a message using the public-key encryption algorithm. The queuing theory is applied to evaluate the performance of our proposed model. We estimated the service time for each queue of the CPU, database, and network, and measured the response time and possible bottlenecks of the model. The capacity of the model is estimated to process the medical records of about 4000 patients/h in the 1-MB network backbone environments, which comprises about the 4% of the total outpatients in Taiwan.

  13. An Analysis of the Medical Records Clerking Occupation.

    ERIC Educational Resources Information Center

    Ridener, Norma A.; And Others

    The general purpose of the occupational analysis is to provide workable, basic information dealing with the many and varied duties performed in the medical records clerk occupation. The document opens with a brief introduction followed by a job description. The bulk of the document is presented in table form. Nine duties are broken down into a…

  14. 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:...

  15. [A mistake in forensic psychiatric evaluation or abuse of psychiatry for non-medical purposes - a case report].

    PubMed

    Florkowski, Antoni; Zboralski, Krzysztof; Macander, Marian; Flinik-Jankowska, Magdalena; Wierzbiński, Piotr

    2015-11-01

    In this study we attempted to visualize certain irregularities that took place in the evaluation of a patient with personality disorders performed by psychiatrist expert witness, which resulted in an incorrect diagnosis, leading to wrong ruling of the court and a referral of the patient to clinical therapy lasting six years. The psychiatric and psychological expert opinions submitted to the court and first-hand psychiatric and psychological examination of the patient were analyzed. Efforts were made to show that the failure to comply with the diagnostic criteria in the process of diagnosis and not taking into account the previously issued five forensic psychiatric opinions issued by independent and experienced teams of psychiatrist expert witnesses, as well as not taking into account the nature of the offense committed have led to a number of irregularities in the assessment of the mental state of the patient. Above mentioned shortcomings have caused unjustified legal classification of the offense and six years long detention of the patient in closed psychiatric institutions, in our regard unnecessary. The described case could be regarded as an abuse of psychiatry for the non-medical purposes and thus should have be punish. Based on the presented case it has been demonstrated that insufficient experience in forensic psychiatry and failure to comply with diagnostic criteria of psychiatrists and psychologists expert witnesses had led to a series of blatant offense of civil rights and liberties, and thus unnecessary detention of the patient for six years.

  16. Medical record keeping and system performance in orthopaedic trauma patients.

    PubMed

    Cosic, Filip; Kimmel, Lara; Edwards, Elton

    2016-02-18

    Objective The medical record is critical for documentation and communication between healthcare professionals. The aim of the present study was to evaluate important aspects of the orthopaedic medical record and system performance to determine whether any deficiencies exist in these areas.Methods Review of 200 medical records of surgically treated traumatic lower limb injury patients was undertaken. The operative report, discharge summary and first and second outpatient reviews were evaluated.Results In all cases, an operative report was completed by a senior surgeon. Weight-bearing status was adequately documented in 91% of reports. Discharge summaries were completed for 82.5% of admissions, with 87.3% of these having instructions reflective of those in the operative report. Of first and second outpatient reviews, 69% and 73%, respectively, occurred within 1 week of the requested time. Previously documented management plans were changed in 30% of reviews. At 6-months post-operatively, 42% of patients had been reviewed by a member of their operating team.Discussion Orthopaedic medical record documentation remains an area for improvement. In addition, hospital out-patient systems perform suboptimally and may affect patient outcomes.What is known about the topic? Medical records are an essential tool in modern medical practice. Despite the importance of comprehensive documentation in the medical record, numerous examples of poor documentation have been demonstrated, including substandard documentation during consultant ward rounds by junior doctors leading to a breakdown in healthcare professional communication and potential patient mismanagement. Further inadequacies of medical record documentation have been demonstrated in surgical discharge notes, with complete and correct documentation reported to be as low as 65%.What does this paper add? Standards of patient care should be constantly monitored and deficiencies identified in order to implement a remedy and close

  17. 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...

  18. 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...

  19. 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...

  20. Psychiatric Residents' Attitudes toward and Experiences with the Clinical-Skills Verification Process: A Pilot Study on U.S. and International Medical Graduates

    ERIC Educational Resources Information Center

    Rao, Nyapati R.; Kodali, Rahul; Mian, Ayesha; Ramtekkar, Ujjwal; Kamarajan, Chella; Jibson, Michael D.

    2012-01-01

    Objective: The authors report on a pilot study of the experiences and perceptions of foreign international medical graduate (F-IMG), United States international medical graduate (US-IMG), and United States medical graduate (USMG) psychiatric residents with the newly mandated Clinical Skills Verification (CSV) process. The goal was to identify and…

  1. Medical Record Clerk Training Program, Course of Study; Instructor's Guide: 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.

    A program of education including training materials is presented to improve the technical proficiency of medical record clerks in small, rural hospitals. The program is planned for fifteen days of instruction or approximately 120 hours including evaluation, orientation and discussion sessions. Students are expected to have a high school diploma…

  2. 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

  3. Medication Adherence, Work Performance and Self-Esteem among Psychiatric Patients Attending Psychosocial Rehabilitation Services at Bangalore, India

    PubMed Central

    Gandhi, Sailaxmi; Pavalur, Rajitha; Thanapal, Sivakumar; Parathasarathy, Nirmala B.; Desai, Geetha; Bhola, Poornima; Philip, Mariamma; Chaturvedi, Santosh K.

    2014-01-01

    Context: Work benefits mental health in innumerable ways. Vocational rehabilitation can enhance self-esteem. Medication adherence can improve work performance and thereby the individuals’ self-esteem. Aim: To test the hypothesis that there would be a significant correlation between medication adherence, work performance and self-esteem. Setting and Design: A quantitative, descriptive correlational research design was adopted to invite patients attending psychiatric rehabilitation services to participate in the research. Material and Methods: Data was collected from a convenience sample of 60 subjects using the ‘Medication Adherence Rating scale’, ‘Griffiths work behaviour scale’ and the ‘Rosenberg's Self-esteem scale’. Statistical analysis used: Analysis was done using spss18 with descriptive statistics, Pearsons correlation coefficient and multiple regression analysis. Results: There were 36 males and 24 females who participated in this study. The subjects had good mean medication adherence of 8.4 ± 1.5 with median of 9.00, high mean self-esteem of 17.65 ± 2.97 with median of 18.0 and good mean work performance of 88.62 ± 22.56 with median of 93.0. Although weak and not significant, there was a positive correlation (r = 0.22, P = 0.103) between medication adherence and work performance; positive correlation between (r = 0.25, P = 0.067) medication adherence and self–esteem; positive correlation between (r = 0.136, P = 0.299) work performance and self-esteem. Multiple regression analysis showed no significant predictors for medication adherence, work performance and self-esteem among patients with psychiatric illness. Conclusions: Medication monitoring and strengthening of work habit can improve self-esteem thereby, strengthening hope of recovery from illness. PMID:25336771

  4. PAMFOnline: integrating EHealth with an electronic medical record system.

    PubMed

    Tang, Paul C; Black, William; Buchanan, Jenny; Young, Charles Y; Hooper, David; Lane, Steven R; Love, Barbara; Mitchell, Charlotte; Smith, Nancy; Turnbull, Jenifer R

    2003-01-01

    The Institute of Medicine stressed the need for continuous healing relationships, yet the delivery of health care has traditionally been confined to the physician office or hospital. We implemented an eHealth application tightly integrated with our electronic medical record system that provides patients with a convenient, continuously available communication channel to their physician's office. Patients can view summary data from their medical record, including the results of diagnostic tests, and request medical advice, prescription renewals, appointments, or updates to their demographic information. We have found that patients embrace this new communication channel and are using the service appropriately. Patients especially value electronic messaging with their physicians and timely access to their test results. While initially concerned about an increase in work, physicians have found that use of electronic messaging can be an efficient method for handling non-urgent communication with their patients. Online tools for patients, when integrated with an electronic medical record, can provide patients with better access to health information, improve patient satisfaction, and improve operational efficiency.

  5. Behaviour management problems as predictors of psychotropic medication and use of psychiatric services in adults with autism.

    PubMed

    Tsakanikos, Elias; Costello, Helen; Holt, Geraldine; Sturmey, Peter; Bouras, Nick

    2007-07-01

    We examined behaviour management problems as predictors of psychotropic medication, use of psychiatric consultation and in-patient admission in a group of 66 adults with pervasive developmental disorder (PDD) and intellectual disability (ID) and 99 controls matched in age, gender and level of ID. Overall, people with PDD had higher rates of most DAS behaviour problems and more frequent use of anti-psychotics than matched controls. Logistic regression analyses showed that physical aggression and problems such as pestering staff independently predicted use of anti-psychotics. Physical aggression and overactivity predicted further involvement of psychiatric services. PDD diagnosis predicted admission to an in-patient unit. The results suggest that externalizing problem behaviours in adults with autism can predict type of treatment intervention.

  6. Implications of Psychiatric Comorbidity Among Combat Veterans

    DTIC Science & Technology

    2013-10-01

    187-97. 30. Feinstein AR: The pre-therapeutic classification of co-morbidity in chronic disease . J Chron Dis 1970; 23: 455-68. 31. Maj M: ’Psychiatric...their medical records included an International Classification of Diseases , Ninth Revision, Clinical Modification diagnostic code between 290.00 and...during the clinical course of . . . disease " (p. 456).^° In recent years, it has been argued that the reported rates of psychiatric comorbidity have

  7. 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.

  8. Using Organizational Development for Electronic Medical Record Transformation.

    PubMed

    Kiel, Joan M

    With mandates requiring the transition from paper medical records to the use of electronic medical records, organizations are embarking on a change process. To engender this process, organizational development models and interventions based predominantly on the theories of Chris Argyris, Warren Bennis, and the team of Paul Lawrence and Jay Lorsch are explored. Interventions are subdivided into behavioral and structural as organizations benefit by recognizing a need for change and, perhaps, a cultural shift in addition to refocusing their mission. To support these interventions, a champion or super user is recommended to maintain the momentum of the transformation and enculturation. With so many changes in the internal and external environments, organizations must respond systematically for, in health care, lives depend on it.

  9. Retrieving Medical Records with sennamed: NEC Labs America at TREC 2012 Medical Records Track

    DTIC Science & Technology

    2012-11-01

    Records track includes a retrieval task aiming to find EMRs that are relevant to a given natural language query[1]. These EMRs are Report Documentation...including radiology, emergency department, and radiology reports. These reports can be grouped into ∼17,000 distinct visits, each corresponding to a...dimensionality reduction, and query expansion. The details of these techniques are given in the next section. Experimental results for each model are presented in

  10. Profile-based Retrieval of Records in Medical Databases

    PubMed Central

    Kementsietsidis, Anastasios; Lim, Lipyeow; Wang, Min

    2009-01-01

    Ontologies establish relationships between different terms, yet their potential in querying has not yet been fully realized. In this paper, we study the problem of ontology-supported profile-based retrieval of medical records. We present an algorithm that provides two independent techniques (used in isolation or in unison) to address the shortcomings of existing keyword-based retrieval solutions, and provide an implementation and experiments to illustrate the merits of our approach. PMID:20351871

  11. Psychiatric illness in the medical profession: incidence in relation to sex and field of practice.

    PubMed Central

    Watterson, D. J.

    1976-01-01

    The overall incidence of psychiatric illness among the physicians of British Columbia during 1970-74 was 1.27% per year. The overall suicide rate was more than 36.5/100 000. Incidence was not dependent on sex or age. The two specialties with the highest incidence--ophthalmology and psychiatry--had previously been demonstrated to have significantly high rates of suicide. The highest incidence was among psychiatric residents; in other resident groups collectively the incidence was at the expected rate. Greater severity of illness and poorer prognosis was found in family physicians compared with specialists, although the incidence was the same in the two groups. PMID:953898

  12. Library instruction within the medical record administration curriculum.

    PubMed Central

    Marcotte, J M; Graves, K J

    1981-01-01

    A course for medical record administration (MRA) students has been developed at the University of Tennessee Center for the Health Sciences Library. The course's objectives are: (1) to train students in the use of the resources and services of health sciences libraries and (2) to provide basic instruction in the organization, operation, and management of a small hospital library. These objectives are met by integrating library use instruction within the MRA curriculum and by presenting a five-week hospital library management workshop. Library use instruction includes a library orientation and sessions on the use of major reference sources, writing for publication, and the use and evaluation of the medical record literature. The workshop covers the role of the medical record administrator as manager of the hospital library. Sessions cover basic principles of hospital library administration, technical and public services, and sources of outside assistance. Results are reported of a survey of graduates conducted to determine whether a need for the course still existed and if the changes made as a result of the evaluation process were appropriate. The teaching methods and evaluation techniques used in this course are applicable to library instruction in other disciplines. PMID:7225659

  13. War neuroses and Arthur Hurst: a pioneering medical film about the treatment of psychiatric battle casualties.

    PubMed

    Jones, Edgar

    2012-07-01

    From 1917 to 1918, Major Arthur Hurst filmed shell-shocked patients home from the war in France. Funded by the Medical Research Committee, and using Pathé cameramen, he recorded soldiers who suffered from intractable movement disorders as they underwent treatment at the Royal Victoria Hospital in Netley and undertook programs of occupational therapy at Seale Hayne in Devon. As one of the earliest UK medical films, Hurst's efforts may have drawn inspiration from the official documentary of the Battle of the Somme and films made in 1916 by French Army neurologists. Although initially motivated to make use of a novel medium to illustrate lectures, Hurst was alert to the wider appeal of the motion picture and saw an opportunity to position himself in the postwar medical hierarchy. Some "before treatment" shots were reenacted for the camera. Hurst, like some other shell shock doctors, openly used deception as a therapeutic measure. On the basis that the ends justified the means, they defended this procedure as ethical. Clinicians also took advantage of changes in military regulations to address functional symptoms. Claims made of "cures" in the film and associated publications by Hurst were challenged by other doctors treating shell shock. The absence of follow-up data and evidence from war pension files suggested that Hurst may have overstated the effectiveness of his methods. Nevertheless, the message conveyed in the film that chronic cases could be treated in a single session had a powerful resonance for ambitious or charismatic doctors and was revived in World War II.

  14. War Neuroses and Arthur Hurst: A Pioneering Medical Film about the Treatment of Psychiatric Battle Casualties

    PubMed Central

    Jones, Edgar

    2016-01-01

    From 1917 to 1918, Major Arthur Hurst filmed shell-shocked patients home from the war in France. Funded by the Medical Research Committee, and using Pathé cameramen, he recorded soldiers who suffered from intractable movement disorders as they underwent treatment at the Royal Victoria Hospital in Netley and undertook programs of occupational therapy at Seale Hayne in Devon. As one of the earliest UK medical films, Hurst’s efforts may have drawn inspiration from the official documentary of the Battle of the Somme and films made in 1916 by French Army neurologists. Although initially motivated to make use of a novel medium to illustrate lectures, Hurst was alert to the wider appeal of the motion picture and saw an opportunity to position himself in the postwar medical hierarchy. Some “before treatment” shots were reenacted for the camera. Hurst, like some other shell shock doctors, openly used deception as a therapeutic measure. On the basis that the ends justified the means, they defended this procedure as ethical. Clinicians also took advantage of changes in military regulations to address functional symptoms. Claims made of “cures” in the film and associated publications by Hurst were challenged by other doctors treating shell shock. The absence of follow-up data and evidence from war pension files suggested that Hurst may have overstated the effectiveness of his methods. Nevertheless, the message conveyed in the film that chronic cases could be treated in a single session had a powerful resonance for ambitious or charismatic doctors and was revived in World War II. PMID:21596724

  15. 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.

  16. Validity of Childhood Autism in the Danish Psychiatric Central Register: Findings from a Cohort Sample Born 1990-1999

    ERIC Educational Resources Information Center

    Lauritsen, Marlene B.; Jorgensen, Meta; Madsen, Kreesten M.; Lemcke, Sanne; Toft, Susanne; Grove, Jakob; Schendel, Diana E.; Thorsen, Poul

    2010-01-01

    The purpose of this study was to assess the validity of the diagnosis of childhood autism in the Danish Psychiatric Central Register (DPCR) by reviewing medical records from 499 of 504 total children with childhood autism born 1990-1999. Based on review of abstracted behaviors recorded in case records from child psychiatric hospitals, case status…

  17. [Comparison of Aggressive Behavior, Compulsory Medication and Absconding Behavior Between Open and Closed door Policy in an Acute Psychiatric Ward].

    PubMed

    Cibis, Mara-Lena; Wackerhagen, Carolin; Müller, Sabine; Lang, Undine E; Schmidt, Yvonne; Heinz, Andreas

    2017-04-01

    Objective According to legal requirements coercive treatment must be limited to acts necessary for the protection of patients and cannot be used for institutional interests. Here, we aimed to test the hypothesis that opening psychiatric wards can reduce the number of aggressive assaults and of coercive treatment without increasing absconding rates. Methods Numbers of absconding, coercive medication, fixation and special security actions were collected retrospectively and compared between phases of closed (N total = 409; N legally committed = 64) and 90 % of daytime opened (N total = 571; N legally committed = 99) doors in an acute psychiatric ward. Results During the phase of opened doors we observed significantly reduced aggressive assaults (p < 0,001) and coercive medication (p = 0,006) compared to the closed setting, while the absconding rate did not change (p = 0,20). Limitation Given the retrospective non-experimental design, no causal interpretations can be drawn. Conclusion The results suggest that open door is associated with reduction of aggressive assaults and coercive medication without increasing absconding rates. This speaks for a stronger implementation of open door policies in acute wards in order to preserve human rights in psychiatry. To collect more robust evidence for this thesis, longer phases should be monitored and moderating variables such as atmosphere and social cohesion should be assessed.

  18. Disclosure of psychiatric manifestations of 22q11.2 deletion syndrome in medical genetics: a 12-year, retrospective chart review

    PubMed Central

    Baughman, Serena Talcott; Morris, Emily; Jensen, Kimberly; Austin, Jehannine

    2015-01-01

    Individuals with 22q11.2 Deletion Syndrome (22qDS) have increased risk for psychiatric disorders. However, while medical geneticists self-report discussing psychiatric features of 22qDS with families (though often only when the child is older), most parents of children with 22qDS report receiving information about the psychiatric manifestations of 22qDS from non-medical sources. In an attempt to reconcile these previous findings, we sought to objectively determine the frequency with which medical geneticists discuss the potential psychiatric manifestations of 22qDS: a) in letters to referring physicians, and b) with families, and to explore plans for follow up. We abstracted data from charts of patients with 22qDS who were referred to a single medical genetics centre between January 1, 2000 and December 31, 2012. Psychiatric disorders were discussed in consult letters to referring physicians for n=57 (46%) of the 125 patients who met inclusion criteria – making them less frequently discussed than all other features of 22qDS. Despite exhaustive review of charts, the content of discussions with families was typically unclear. Follow-up in medical genetics was suggested for 50 people but only 18 (36%) of these patients returned. Disclosure of psychiatric features of 22qDS to families is necessary so that psychiatric disorders can be identified in time for early intervention to be implemented to achieve better prognosis for those affected. These empiric data offer some explanation as to why psychiatric services are underused by individuals with 22qDS. PMID:26033850

  19. Disclosure of psychiatric manifestations of 22q11.2 deletion syndrome in medical genetics: A 12-year retrospective chart review.

    PubMed

    Baughman, Serena Talcott; Morris, Emily; Jensen, Kimberly; Austin, Jehannine

    2015-10-01

    Individuals with 22q11.2 deletion syndrome (22qDS) have increased risk for psychiatric disorders. However, while medical geneticists self-report discussing psychiatric features of 22qDS with families (though often only when the child is older), most parents of children with 22qDS report receiving information about the psychiatric manifestations of 22qDS from non-medical sources. In an attempt to reconcile these previous findings, we sought to objectively determine the frequency with which medical geneticists discuss the potential psychiatric manifestations of 22qDS: (i) in letters to referring physicians and (ii) with families, and to explore plans for follow-up. We abstracted data from charts of patients with 22qDS who were referred to a single medical genetics center between January 1, 2000 and December 31, 2012. Psychiatric disorders were discussed in consult letters to referring physicians for n = 57 (46%) of the 125 patients who met inclusion criteria-making them less frequently discussed than all other features of 22qDS. Despite exhaustive review of charts, the content of discussions with families was typically unclear. Follow-up in medical genetics was suggested for 50 people but only 18 (36%) of these patients returned. Disclosure of psychiatric features of 22qDS to families is necessary so that psychiatric disorders can be identified in time for early intervention to be implemented to achieve better prognosis for those affected. These empiric data offer some explanation as to why psychiatric services are underused by individuals with 22qDS.

  20. 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

  1. 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... ADMINISTRATION PRIVACY ACT PROGRAM Giving Access to Privacy Act Records § 806b.17 Special provision for certain medical records. If a physician believes that disclosing requested medical records could harm the...

  2. 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...

  3. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 2 2010-07-01 2010-07-01 false Access to medical and psychological records. 324... DEFENSE (CONTINUED) PRIVACY PROGRAM DFAS PRIVACY ACT PROGRAM Individual Access to Records § 324.13 Access to medical and psychological records. Individual access to medical and psychological records...

  4. 28 CFR 549.46 - Procedures for involuntary administration of psychiatric medication.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... subpart, a psychiatric emergency exists when a person suffering from a mental illness or disorder creates... the mental illness or disorder, the inmate is dangerous to self or others, poses a serious threat of... the mental illness or disorder and its symptoms, and alternatives (e.g., seclusion or...

  5. 28 CFR 549.46 - Procedures for involuntary administration of psychiatric medication.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... subpart, a psychiatric emergency exists when a person suffering from a mental illness or disorder creates... the mental illness or disorder, the inmate is dangerous to self or others, poses a serious threat of... the mental illness or disorder and its symptoms, and alternatives (e.g., seclusion or...

  6. 28 CFR 549.46 - Procedures for involuntary administration of psychiatric medication.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... subpart, a psychiatric emergency exists when a person suffering from a mental illness or disorder creates... the mental illness or disorder, the inmate is dangerous to self or others, poses a serious threat of... the mental illness or disorder and its symptoms, and alternatives (e.g., seclusion or...

  7. Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers

    PubMed Central

    Wittels, Kathleen; Wallenstein, Joshua; Patwari, Rahul; Patel, Sundip

    2017-01-01

    Introduction Electronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships. Methods We performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted. Results We received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%). Conclusion Close to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student

  8. Giving patients a copy of their computer medical record.

    PubMed

    Sheldon, M G

    1982-02-01

    Medical summaries were prepared by a general practitioner for inclusion in a computer system. Both the medical records and a patient-filled questionnaire were used. A representative sample of the practice population were then sent their summaries. In creating the summaries the general practitioner felt the need to exclude 11 diagnoses whenever they appeared (5 per cent of the patients), and to suppress one or more diagnoses in a further 14 per cent of patients. In 2 per cent of summaries the general practitioner felt unable to give a copy to the patient because he was afraid of an adverse reaction by the patient or immediate relatives.The patients' views of the usefulness of the summaries, and of their accuracy and completeness, were sought by a questionnaire. Replies were received from 71 per cent; of these, 91 per cent reported that they thought the summary useful. However, in 18 per cent of cases, the patients requested additions, corrections or deletions. Only 1 per cent of patients replied that they definitely did not like the idea of a computer containing their medical information.Some of the benefits and difficulties both of using a computer to store medical information, and of giving the patient a copy of the medical summary, are discussed.

  9. 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

  10. A Review of the Differences in Developmental, Psychiatric, and Medical Endophenotypes Between Males and Females with Autism Spectrum Disorder

    PubMed Central

    Rubenstein, Eric; Wiggins, Lisa D.; Lee, Li-Ching

    2015-01-01

    Autism spectrum disorder (ASD) is over four times more prevalent in males compared to females. Increased understanding of sex differences in ASD endophenotypes could add insight into possible etiologies and the assessment and management of the disorder. Consequently, the purpose of this review is to describe current literature regarding sex differences in the developmental, psychiatric, and medical endophenotypes of ASD in order to illustrate current knowledge and areas in need of further research. Our review found that repetitive behaviors and restricted interests are more common in males than females with ASD. Intellectual disability is more common in females than males with ASD. Attention to detail may be more common in males than females with ASD and epilepsy may be more common in females than males with ASD, although limited research in these areas prevent definitive conclusions from being drawn. There does not appear to be a sex difference in other developmental, psychiatric, and medical symptoms associated with ASD, or the research was contradictory or too sparse to establish a sex difference. Our review is unique in that it offers detailed discussion of sex differences in three major endophenotypes of ASD. Further research is needed to better understand why sex differences exist in certain ASD traits and to evaluate whether phenotypic sex differences are related to different pathways of development, assessment, and treatment of the disorder. PMID:26146472

  11. 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

  12. Evaluation of a BCMA’s Electronic Medication Administration Record

    PubMed Central

    Staggers, Nancy; Iribarren, Sarah; Guo, Jia-Wen; Weir, Charlene

    2015-01-01

    Barcode medication administration (BCMA) systems can reduce medication errors, but sociotechnical issues are quite common. Although crucial to nurses’ work, few usability evaluations are available for electronic medication administration record screens (eMARs). The purpose of this research was to identify current usability problems in the VA’s eMAR/BCMA system and explore how these might impact nurses’ situation awareness. Three expert evaluators used 10 tasks/elements, heuristic evaluation techniques and explored potential impacts using a situation awareness perspective. The results yielded 99 usability problems categorized into 440 heuristic violations with the largest volume in the category of Match with the Real World. Fifteen usability issues were rated as catastrophic with the Administer/Chart medications task having the most. Situational awareness was impacted at all levels, especially at Level 2, Comprehension. Usability problems point to important areas for improvement because these issues have the potential to impact nurses’ situation awareness, “at a glance” information, nurse productivity and patient safety. PMID:25601936

  13. Medical guidelines presentation and comparing with Electronic Health Record.

    PubMed

    Veselý, Arnost; Zvárová, Jana; Peleska, Jan; Buchtela, David; Anger, Zdenek

    2006-01-01

    Electronic Health Record (EHR) systems are now being developed in many places. More advanced systems provide also reminder facilities, usually based on if-then rules. In this paper we propose a method how to build the reminder facility directly upon the guideline interchange format (GLIF) model of medical guidelines. The method compares data items on the input of EHR system with medical guidelines GLIF model and is able to reveal if the input data item, that represents patient diagnosis or proposed patient treatment, contradicts with medical guidelines or not. The reminder facility can be part of EHR system itself or it can be realized by a stand-alone reminder system (SRS). The possible architecture of stand-alone reminder system is described in this paper and the advantages of stand-alone solution are discussed. The part of the EHR system could be also a browser that would present graphical GLIF model in easy to understand manner on the user screen. This browser can be data driven and focus attention of user to the relevant part of medical guidelines GLIF model.

  14. Disciplined doctors: the electronic medical record and physicians' changing relationship to medical knowledge.

    PubMed

    Reich, Adam

    2012-04-01

    This study explores the effects of the electronic medical record (EMR) on the power of the medical profession. It is based on twenty-five in-depth interviews with administrators and physicians across three departments of a large, U.S. integrated health system, as well as ethnographic observation, all of which took place between September of 2009 and December of 2010. While scholarship on professional power has tended toward the opposite poles of professional dominance and deprofessionalization or proletarianization, I find that doctors' interactions with the EMR reconcile these perspectives by making physicians' professional identities consistent with their subordination to bureaucratic authority. After examining the electronic medical record as a disciplinary technology, the paper analyzes variation in the extent to which practitioners' professional identities are reconciled with bureaucratic subordination across the different departments studies.

  15. The University of Washington electronic medical record experience*

    PubMed Central

    Welton, Nanette J

    2010-01-01

    The Health Sciences Library at the University of Washington initiated and continues to develop a role in the electronic medical record, starting with the development of the first integrated web-based interface, called MINDscape. An Integrated Academic Information Management System (IAIMS) grant in 1992 began the process, which also led to the development of a clinical medical librarian position. Over the years, the librarian's role in the clinical environment became more established, and with the advent of clinical online resources, it offered further opportunities for librarians to provide the expertise needed to incorporate the appropriate resources. The collaborative journey continues as librarians, now able to directly access the EMRs, provide information about what resources to use and where best to place them and design how best to provide notes or feedback to clinicians. PMID:20648254

  16. Financial analysis projects clear returns from electronic medical records.

    PubMed

    Schmitt, Karl F; Wofford, David A

    2002-01-01

    Implementing an electronic medical record (EMR) is a major initiative that should be undertaken only after a thoughtful analysis of the costs and benefits involved. Unfortunately, demonstrating financial returns on an EMR often is regarded as an inexact science at best, which has caused many healthcare executives to avoid adopting this technology. With the right approach, however, it is possible to demonstrate convincingly that the financial benefits will far outweigh the costs. To do this, it is necessary to involve representatives from operational areas throughout the organization, because they are best able to identify the potential for cost savings and additional revenue opportunities.

  17. Virtual medical record implementation for enhancing clinical decision support.

    PubMed

    Gomoi, Valentin-Sergiu; Dragu, Daniel; Stoicu-Tivadar, Vasile

    2012-01-01

    Development of clinical decision support systems (CDS) is a process which highly depends on the local databases, this resulting in low interoperability. To increase the interoperability of CDS a standard representation of clinical information is needed. The paper suggests a CDS architecture which integrates several HL7 standards and the new vMR (virtual Medical Record). The clinical information for the CDS systems (the vMR) is represented with Topic Maps technology. Beside the implementation of the vMR, the architecture integrates: a Data Manager, an interface, a decision making system (based on Egadss), a retrieving data module. Conclusions are issued.

  18. 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.

  19. 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.

  20. Construction and Validation of Synthetic Electronic Medical Records

    PubMed Central

    Moniz, Linda; Buczak, Anna L.; Hung, Lang; Babin, Steven; Dorko, Michael; Lombardo, Joseph

    2009-01-01

    There is a current and pressing need for a test bed of electronic medical records (EMRs) to insure consistent development, validation and verification of public health related algorithms that operate on EMRs. However, access to full EMRs is limited and not generally available to the academic algorithm developers who support the public health community. This paper describes a set of algorithms that produce synthetic EMRs using real EMRs as a model. The algorithms were used to generate a pilot set of over 3000 synthetic EMRs that are currently available on CDC’s Public Health grid. The properties of the synthetic EMRs were validated, both in the entire aggregate data set and for individual (synthetic) patients. We describe how the algorithms can be extended to produce records beyond the initial pilot data set. PMID:23569572

  1. 77 FR 55221 - Agency Information Collection Activities: Report of Medical Examination and Vaccination Record...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-09-07

    ... Medical Examination and Vaccination Record, Form I-693; Revision of a Currently Approved Collection ACTION...: Report of Medical Examination and Vaccination Record. (3) Agency form number, if any, and the...

  2. Psychiatric disorders and sleep issues.

    PubMed

    Sutton, Eliza L

    2014-09-01

    Sleep issues are common in people with psychiatric disorders, and the interaction is complex. Sleep disorders, particularly insomnia, can precede and predispose to psychiatric disorders, can be comorbid with and exacerbate psychiatric disorders, and can occur as part of psychiatric disorders. Sleep disorders can mimic psychiatric disorders or result from medication given for psychiatric disorders. Impairment of sleep and of mental health may be different manifestations of the same underlying neurobiological processes. For the primary care physician, key tools include recognition of potential sleep effects of psychiatric medications and familiarity with treatment approaches for insomnia in depression and anxiety.

  3. Leveraging electronic health records to study pleiotropic effects on bipolar disorder and medical comorbidities

    PubMed Central

    Prieto, M L; Ryu, E; Jenkins, G D; Batzler, A; Nassan, M M; Cuellar-Barboza, A B; Pathak, J; McElroy, S L; Frye, M A; Biernacka, J M

    2016-01-01

    Patients with bipolar disorder (BD) have a high prevalence of comorbid medical illness. However, the mechanisms underlying these comorbidities with BD are not well known. Certain genetic variants may have pleiotropic effects, increasing the risk of BD and other medical illnesses simultaneously. In this study, we evaluated the association of BD-susceptibility genetic variants with various medical conditions that tend to co-exist with BD, using electronic health records (EHR) data linked to genome-wide single-nucleotide polymorphism (SNP) data. Data from 7316 Caucasian subjects were used to test the association of 19 EHR-derived phenotypes with 34 SNPs that were previously reported to be associated with BD. After Bonferroni multiple testing correction, P<7.7 × 10−5 was considered statistically significant. The top association findings suggested that the BD risk alleles at SNP rs4765913 in CACNA1C gene and rs7042161 in SVEP1 may be associated with increased risk of ‘cardiac dysrhythmias' (odds ratio (OR)=1.1, P=3.4 × 10−3) and ‘essential hypertension' (OR=1.1, P=3.5 × 10−3), respectively. Although these associations are not statistically significant after multiple testing correction, both genes have been previously implicated with cardiovascular phenotypes. Moreover, we present additional evidence supporting these associations, particularly the association of the SVEP1 SNP with hypertension. This study shows the potential for EHR-based analyses of large cohorts to discover pleiotropic effects contributing to complex psychiatric traits and commonly co-occurring medical conditions. PMID:27529678

  4. 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...

  5. 32 CFR 324.13 - Access to medical and psychological records.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 32 National Defense 2 2011-07-01 2011-07-01 false Access to medical and psychological records. 324.13 Section 324.13 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF... to medical and psychological records. Individual access to medical and psychological records...

  6. 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…

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

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 10 Energy 1 2014-01-01 2014-01-01 false Records of dosages of unsealed byproduct material for 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)...

  8. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Records of dosages of unsealed byproduct material for 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)...

  9. 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...

  10. 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...

  11. 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...

  12. 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...

  13. 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...

  14. 32 CFR 1901.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 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 are... 32 National Defense 6 2010-07-01 2010-07-01 false Special procedures for medical and...

  15. School Administration Handbook for Approved Schools for Medical Record Technicians. Revised April 66.

    ERIC Educational Resources Information Center

    American Association of Medical Record Librarians, Chicago, IL.

    These guidelines are for the development and operation of approved programs to prepare medical record technicians. "School Approval" discusses the cooperative roles of the American Medical Association (AMA) Council on Medical Education and the American Association of Medical Record Librarians (AAMRL) in connection with program approval,…

  16. Psychiatric emergencies.

    PubMed

    Cavanaugh, S V

    1986-09-01

    Psychiatric disorders are common in medical inpatient and outpatient populations. As a result, internists commonly are the first to see psychiatric emergencies. As with all medical problems, a good history, including a collateral history from relatives and friends, physical and mental status examination, and appropriate laboratory tests help establish a preliminary diagnosis and treatment plan. Patients with suicidal ideation usually have multiple stressors in the environment and/or a psychiatric disorder (i.e., a major affective disorder, dysthymic disorder, anxiety or panic disorder, psychotic disorder, alcohol or drug abuse, a personality disorder, and/or an adjustment disorder). Of all patients who commit suicide, 70% have a major depressive disorder, schizophrenia, psychotic organic mental disorder, alcoholism, drug abuse, and borderline personality disorder. Patients who are at great risk have minimal supports, a history of previous suicide attempts, a plan with high lethality, hopelessness, psychosis, paranoia, and/or command self-destructive hallucinations. Treatment is directed toward placing the patient in a protected environment and providing psychotropic medication and/or psychotherapy for the underlying psychiatric problem. Other psychiatric emergencies include psychotic and violent patients. Psychotic disorders fall into two categories etiologically: those that have an identifiable organic factor causing the psychosis and those that have an underlying psychiatric disorder. Initially, it is essential to rule out organic pathology that is life-threatening or could cause irreversible brain damage. After such organic causes are ruled out, neuroleptic medication is indicated. If the patient is not agitated or combative, he or she may be placed on oral divided doses of neuroleptics in the antipsychotic range. Patients who are agitated or psychotic need rapid tranquilization with an intramuscular neuroleptic every half hour to 1 hour until the agitation and

  17. Medical diagnosis of legal culpability: the impact of early psychiatric testimony in the 19th century English criminal trial.

    PubMed

    Toole, Ciara J

    2012-01-01

    Fast-paced developments in psychiatry, neuroscience and emerging neuroimaging technologies place continual pressure on the legal recognition of mental illness and disease across jurisdictional boundaries. Nevertheless, the Canadian legal definition of exculpatory mental disease in the context of criminal liability has remained largely static, sheltered from the immediate influence of medical theory and advancements. In order to effectively reflect on the intersection of mental health and criminal justice systems in this area, it is important to understand its historical development and the English common law origins of the current approach. Specifically turning to the early 19th century, documented history and accounts of early medical witness testimony on the mental state of the accused provide a unique opportunity to understand the initial collision between fundamental concepts of moral and legal culpability and new scientific understandings of mental function and disease. In this article, I suggest that early psychiatric testimony to the accused's mental state challenged the evolving criminal law of 19th century England to reconcile its restrictive definition of "insanity" with expanding scientific reasoning and accounts of mental disease. The trial of Edward Oxford, an attempted royal assassination case of 1840, is examined as a symbolic height in this conflict prior to the first common law pronouncement of the current approach in 1843. As debate continues on the role of medical advancement in the identification of exculpatory medical disorders in law, this historical perspective may serve as a touchstone in balancing the enforcement of legal culpability with our society's greater appreciation for mental illness.

  18. Conflations of Marital Status and Sanity: Implicit Heterosexist Bias in Psychiatric Diagnosis in Physician-Dictated Charts at a Midwestern Medical Center

    PubMed Central

    Metzl, Jonathan M.; McClelland, Sara I.; Bergner, Erin

    2016-01-01

    This paper discusses the role of gender role conformity in psychiatric determinants of well-being after of the depathologization of homosexuality from the DSM. In order to examine the heterosexualizing of sanity in U.S. psychiatric and popular cultures, we analyze archived psychiatrist-dictated patient charts from outpatient psychiatric clinics from a Midwestern medical center (n = 45). We highlight ways physicians deployed heteronormative gender expectations to describe and treat women’s and men’s depressive illness and implicitly construed troubled female-male relationships and sexual encounters as indices of psychopathology. We theorize how evolving connections between the heteronormal and the psychiatric normal performed some of the same regulatory functions, as did the DSM, coding particular gender performances and partner choices as mentally healthy while relegating others to the realm of disease. Only here, focusing on the mainstream instead of the marginalized kept the ideological work of these scripts hidden from view. PMID:27354850

  19. 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... whether to disclose the record shall be made in the first instance by the system manager. (b)...

  20. 42 CFR 482.24 - Condition of participation: Medical record services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ..., filing, and retrieval of records. (b) Standard: Form and retention of record. The hospital must maintain... medical records. The system must allow for timely retrieval by diagnosis and procedure, in order...

  1. Incidence and types of preventable adverse events in elderly patients: population based review of medical records

    PubMed Central

    Thomas, Eric J; Brennan, Troyen A

    2000-01-01

    Objective To determine the incidence and types of preventable adverse events in elderly patients. Design Review of random sample of medical records in two stage process by nurses and physicians to detect adverse events. Two study investigators then judged preventability. Setting Hospitals in US states of Utah and Colorado, excluding psychiatric and Veterans Administration hospitals. Subjects 15 000 hospitalised patients discharged in 1992. Main outcome measures Incidence of preventable adverse events (number of preventable events per 100 discharges) in elderly patients (⩾65 years old) and non-elderly patients (16-64 years). Results When results were extrapolated to represent all discharges in 1992 in both states, non-elderly patients had 8901 adverse events (incidence 2.80% (SE 0.18%)) compared with 7419 (5.29% (0.37%)) among elderly patients (P=0.001). Non-elderly patients had 5038 preventable adverse events (incidence 1.58% (0.14%)) compared with 4134 (2.95% (0.28%)) in elderly patients (P=0.001). Elderly patients had a higher incidence of preventable events related to medical procedures (such as thoracentesis, cardiac catheterisation) (0.69% (0.14%) v 0.13% (0.04%)), preventable adverse drug events (0.63% (0.14%) v 0.17% (0.05%)), and preventable falls (0.10% (0.06%) v 0.01% (0.02%)). In multivariate analyses, adjusted for comorbid illnesses and case mix, age was not an independent predictor of preventable adverse events. Conclusions Preventable adverse events were more common among elderly patients, probably because of the clinical complexity of their care rather than age based discrimination. Preventable adverse drug events, events related to medical procedures, and falls were especially common in elderly patients and should be targets for efforts to prevent errors. PMID:10720355

  2. Attitudes of Medical Students towards Psychiatry: Effects of Training, Courses in Psychiatry, Psychiatric Experience and Gender

    ERIC Educational Resources Information Center

    Kuhnigk, Olaf; Strebel, Bernd; Schilauske, Joerg; Jueptner, Markus

    2007-01-01

    Objective: The attitudes of medical students towards psychiatry and psychotherapy were examined considering the extent of their education, previous psychiatry experience, the evaluation of the course, their career intentions and socio-demographic variables. Methods: Five hundred and eight medical students in their second, fifth, ninth and tenth…

  3. Psychiatric Correlates of Medical Care Costs among Veterans Receiving Mental Health Care

    ERIC Educational Resources Information Center

    Simpson, Tracy L.; Moore, Sally A.; Luterek, Jane; Varra, Alethea A.; Hyerle, Lynne; Bush, Kristen; Mariano, Mary Jean; Liu, Chaun-Fen; Kivlahan, Daniel R.

    2012-01-01

    Research on increased medical care costs associated with posttraumatic sequelae has focused on posttraumatic stress disorder (PTSD). However, the provisional diagnosis of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) encompasses broader trauma-related difficulties and may be uniquely related to medical costs. We investigated whether…

  4. Change Management – Recommendations for Successful Electronic Medical Records Implementation

    PubMed Central

    Shoolin, J.S.

    2010-01-01

    Summary Change is difficult and managing change even more so. With the advent of Electronic Medical Records (EMRs) and the difficulty of its acceptance, understanding physician’s attitudes and the psychology of change management is imperative. While many authors describe change management theories, one comes nearest to describing this particularly difficult transition. In 1969, Elizabeth Kübler-Ross wrote her seminal treatise, On Death and Dying, detailing the psychological changes terminally ill patients undergo. Her grieving model is a template to examine the impact of change. By following a physician through the EMR maze, understanding the difficulties he/she perceives and developing a plan other change agents are able to use, the paper gives practical recommendations to EMR change management. PMID:23616842

  5. 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.

  6. 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

  7. Clinical utility of varenicline for smokers with medical and psychiatric comorbidity

    PubMed Central

    Ebbert, Jon O; Wyatt, Kirk D; Zirakzadeh, Ali; Burke, Michael V; Hays, JT

    2009-01-01

    Chronic obstructive pulmonary disease (COPD) is a costly and deadly disease afflicting an estimated 210 million people and accounting for 5% of all global deaths. Exposure to cigarette smoke is the greatest risk factor for COPD in the developed world. Smoking cessation improves respiratory symptoms and lung function and reduces mortality among patients with COPD. Cigarette smokers with COPD and other co-morbid conditions such as cardiovascular disease and psychiatric illnesses should receive comprehensive tobacco treatment interventions incorporating efficacious pharmacotherapies. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, is the newest and most effective drug currently available to promote smoking cessation. In conjunction with behavioral interventions and clinical monitoring for potential side effects, varenicline offers great hope for reducing smoking-attributable death and disability. PMID:20037681

  8. Integration of a Psychiatric Service in a Long-Term Charitable Facility for People with Intellectual Disabilities: A 5-Year Medication Survey

    ERIC Educational Resources Information Center

    Ruggerini, Ciro; Guaraldi, Gian Paolo; Russo, Angela; Neviani, Vittoria; Castagnini, Augusto

    2004-01-01

    Since the implementation of a psychiatric service in a long-term facility for people with intellectual disability, the usage of psychotropic and anti-convulsant drugs has been surveyed over the 5-year period 1994-1999. At that time, although the overall prevalence rate of residents on medication was not declining significantly, a decrease in…

  9. Psychotropics without borders: ethics and legal implications of internet-based access to psychiatric medications.

    PubMed

    Klein, Carolina A

    2011-01-01

    Medical practitioners are revisiting many of the ethics and the legal implications surrounding the clinical frameworks within which we operate. In today's world, distinguishing between virtual and physical reality continues to be increasingly difficult. The physician may be found grappling with the decision of whether to continue to treat a patient who may be obtaining psychotropic medications through the Internet. This article approaches some of the clinical and legal implications and the ethics regarding the availability of prescription psychotropics over the Internet.

  10. 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...

  11. 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...

  12. 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...

  13. Roles of Medical Record and Statistic Staff on Research at the Tawanchai Center.

    PubMed

    Pattaranit, Rumpan; Chantachum, Vasana; Lekboonyasin, Orathai; Pradubwong, Suteera

    2015-08-01

    The medical record and statistic staffs play a crucial role behind the achievements of treatment and research of physicians, nurses and other health care professionals. The medical record and statistic staff are in charge of keeping patient medical records; creating databases; presenting information; sorting patient's information; providing patient medical records and related information for various medical teams and researchers; Besides, the medical record and statistic staff have collaboration with the Center of Cleft Lip-Palate, Khon Kaen University in association with the Tawanchai Project. The Tawanchai Center is an organization, involving multidisciplinary team which aims to continuing provide care for patients with cleft lip and palate and craniofacial deformities who need a long term of treatment since newborns until the age of 19 years. With support and encouragement from the Tawanchai team, the medical record and statistic staff have involved in research under the Tawanchai Centre since then and produced a number of publications locally and internationally.

  14. 33 CFR 150.604 - Who controls access to medical monitoring and exposure records?

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 33 Navigation and Navigable Waters 2 2010-07-01 2010-07-01 false Who controls access to medical... Health Safety and Health (general) § 150.604 Who controls access to medical monitoring and exposure records? If medical monitoring is performed or exposure records are maintained by an employer, the...

  15. 10 CFR 35.2063 - Records of dosages of unsealed byproduct material for medical use.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 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,...

  16. Psychiatric treatment for extremely traumatized civil war refugees from former Yugoslavia. Possibilities and limitations of integrating psychotherapy and medication.

    PubMed

    Schwarz-Langer, Gertrud; Deighton, Russell R; Jerg-Bretzke, Lucia; Weisker, Ingo; Traue, Harald C

    2006-01-01

    Patients with a history of extremely traumatic experiences show a complex pattern of psychological and physical disorders which represents a special challenge for psychiatric care. This problem is described using the example of the psychiatric/psychotherapeutic treatment of 13 civil war refugees with a history of traumatic experiences from former Yugoslavia in psychiatric treatment at the Psychiatric Clinic of the University of Ulm. One substantial problem encountered by these patients is that, in addition to the original traumatization in their country of origin, the unstable psychosocial conditions of their legal exile condition can lead to re-traumatization which must be responded to with psychiatric treatment.

  17. Co-occurring psychiatric symptoms are associated with increased psychological, social, and medical impairment in opioid dependent pregnant women.

    PubMed

    Benningfield, Margaret M; Arria, Amelia M; Kaltenbach, Karol; Heil, Sarah H; Stine, Susan M; Coyle, Mara G; Fischer, Gabriele; Jones, Hendrée E; Martin, Peter R

    2010-01-01

    The interaction of psychiatric symptoms with drug dependence during pregnancy is not well understood. This study examines the relationship of psychiatric symptoms to severity of drug use and drug-related problems among participants in a clinical trial of pharmacologic treatment of opioid dependence during pregnancy (N = 174). A total of 64.6% reported additional psychiatric symptoms (48.6% mood symptoms, 40.0% anxiety symptoms, and 12.6% suicidal thinking). Women who endorsed co-occurring psychiatric symptoms showed more severe impairment on the Addiction Severity Index. Further investigation is warranted to understand the effect of psychiatric symptoms on long-term maternal and neonatal outcomes.

  18. Medical, psychiatric and demographic factors associated with suicidal behavior in homeless veterans.

    PubMed

    Goldstein, Gerald; Luther, James Francis; Haas, Gretchen Louise

    2012-08-30

    This study assessed potential for suicidal behaviors associated with sociodemographic, predisposing physical and mental health factors and self-reported psychological problems among homeless veterans in a large northeastern region. Data were obtained from a demographic and clinical history interview conducted with 3595 homeless veterans. Odds-ratio (OR) statistics were used to assess potential for suicidal behavior. Statistically significant ratios were similar for ideation and attempts. The highest ratios were for self-report of depression and difficulty controlling violence, but statistically significant ratios were found for reporting sleeping in a treatment facility the night before the interview, receiving VA support for a psychiatric condition, and the diagnoses of Alcoholism, Mood Disorder and Post Traumatic Stress Disorder (PTSD). Low but statistically significant odds-ratios were obtained for most of the physical health items. A negative odds-ratio was obtained for African-American ethnicity. Logistic regression results indicated that for ideation and attempts items entered first involved subjective report of trouble controlling violent behavior and experiencing depression. High odds ratios for the interview items concerning experiencing serious depression and having difficulties controlling violence may have strong implications for treatment and management of homeless veterans. There may be up to 14-1 odds that an individual who reports being seriously depressed or having difficulty inhibiting aggression may have a serious potential for suicidal behaviors.

  19. 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...

  20. 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...

  1. 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…

  2. 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

    ... 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 of... Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue...

  3. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... modalities utilized; (iv) The responsibilities of each member of the treatment team; and (v) Adequate... worker and, when appropriate, others significantly involved in active treatment modalities. The...

  4. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... modalities utilized; (iv) The responsibilities of each member of the treatment team; and (v) Adequate... worker and, when appropriate, others significantly involved in active treatment modalities. The...

  5. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... modalities utilized; (iv) The responsibilities of each member of the treatment team; and (v) Adequate... worker and, when appropriate, others significantly involved in active treatment modalities. The...

  6. 42 CFR 482.61 - Condition of participation: Special medical record requirements for psychiatric hospitals.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... modalities utilized; (iv) The responsibilities of each member of the treatment team; and (v) Adequate... worker and, when appropriate, others significantly involved in active treatment modalities. The...

  7. 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.

  8. Key success factors behind electronic medical record adoption in Thailand.

    PubMed

    Narattharaksa, Kanida; Speece, Mark; Newton, Charles; Bulyalert, Damrongsak

    2016-09-19

    Purpose The purpose of this paper is to investigate the elements that health care personnel in Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems. Design/methodology/approach Initial qualitative in-depth interviews with physicians to adapt key elements from the literature to the Thai context. The 12 elements identified included things related to managing the implementation and to IT expertise. The nationwide survey was supported by the Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a range of medical personnel. Findings The key elements clearly separated into a managerial dimension and an IT dimension. All were considered fairly important, but managerial expertise was more critical. In particular, there should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be involved in implementation, and the IT should facilitate good electronic communication. Research limitations/implications Thailand is representative of middle-income developing countries, but there is no guarantee findings can be generalized. National policies differ, as do economic structures of health care industries. The focus is on management at the organizational level, but future research must also examine macro-level issues, as well as gain more depth into thinking of individual health care personnel. Practical implications Technical issues of EMR implementation are certainly important. However, it is clear actual adoption and use of the system also depends very heavily on managerial issues. Originality/value Most research on EMR implementation has been in developed countries, and has often focussed more on technical issues rather than examining managerial issues closely. Health IT is also critical in developing economies, and management of health IT implementation must be well understood.

  9. 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.

  10. 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

  11. A Catalog of Psychiatric Medications Used in the Treatment of Child and Adolescent Mental Disorders.

    ERIC Educational Resources Information Center

    James, Susan Hackbarth; Nims, Donald R.

    1996-01-01

    Although school counselors are increasingly involved in administering medications to students with emotional, conduct, and behavioral problems, few counselors have training in psychopharmacology. Gives a brief history of psychopharmacological interventions, and describes usage and side effects of drugs for psychosis, depression, anxiety, and…

  12. Psychiatric Services for Individuals with Intellectual and Developmental Disabilities: Medication Management

    ERIC Educational Resources Information Center

    Russell, Andrew T.; Hahn, Joan Earle; Hayward, Katharine

    2011-01-01

    The purpose of this study was to describe the medication management and treatment provided in a specialty outpatient psychiatry clinic for 198 community-residing children and adults with intellectual disability and other developmental disabilities (IDD) referred to the clinic and discharged between 1999 and 2008. Using a descriptive design, data…

  13. Teaching Medication Compliance to Psychiatric Residents: Placing an Orphan Topic into a Training Curriculum

    ERIC Educational Resources Information Center

    Weiden, Peter J.; Rao, Nyapati

    2005-01-01

    OBJECTIVE: Medication compliance is an orphan topic. Training in the understanding and management of noncompliance does not neatly fall within the domain of psychopharmacology, nor does it clearly fit into other core curricula areas, such as clinical interviewing or psychotherapy training. The objective of this article is to increase awareness…

  14. 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.

  15. The Effects of Promoting Patient Access to Medical Records: A Review

    PubMed Central

    Ross, Stephen E.; Lin, Chen-Tan

    2003-01-01

    The Health Insurance Privacy and Portability Act (HIPPA) stipulates that patients must be permitted to review and amend their medical records. As information technology makes medical records more accessible to patients, it may become more commonplace for patients to review their records routinely. This article analyzes the potential benefits and drawbacks of facilitating patient access to the medical record by reviewing previously published research. Previous research includes analysis of clinical notes, surveys of patients and practitioners, and studies of patient-accessible medical records. Overall, studies suggest the potential for modest benefits (for instance, in enhancing doctor-patient communication). Risks (for instance, increasing patient worry or confusion) appear to be minimal in medical patients. The studies, however, were of limited quality and low statistical power to detect the variety of outcomes that may result from implementation of a patient-accessible medical record. The data from these studies lay the foundation for future research. PMID:12595402

  16. 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

  17. 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

  18. A critical pathway for electronic medical record selection.

    PubMed

    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.

  19. 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

  20. Characterization of Statin Dose-response within Electronic Medical Records

    PubMed Central

    Wei, Wei-Qi; Feng, Qiping; Jiang, Lan; Waitara, Magarya S.; Iwuchukwu, Otito F.; Roden, Dan M.; Jiang, Min; Xu, Hua; Krauss, Ronald M.; Rotter, Jerome I.; Nickerson, Deborah A.; Davis, Robert L.; Berg, Richard L.; Peissig, Peggy L.; McCarty, Catherine A.; Wilke, Russell A.; Denny, Joshua C.

    2013-01-01

    Efforts to define the genetic architecture underlying variable statin response have met with limited success possibly because previous studies were limited to effect based on one-single-dose. We leveraged electronic medical records (EMRs) to extract potency (ED50) and efficacy (Emax) of statin dose-response curves and tested them for association with 144 pre-selected variants. Two large biobanks were used to construct dose-response curves for 2,026 (simvastatin) and 2,252 subjects (atorvastatin). Atorvastatin was more efficacious, more potent, and demonstrated less inter-individual variability than simvastatin. A pharmacodynamic variant emerging from randomized trials (PRDM16) was associated with Emax for both. For atorvastatin, Emax was 51.7 mg/dl in homozygous for the minor allele versus 75.0 mg/dl for those homozygous for the major allele. We also identified several loci associated with ED50. The extraction of rigorously defined traits from EMRs for pharmacogenetic studies represents a promising approach to further understand of genetic factors contributing to drug response. PMID:24096969

  1. Privacy Impact Assessment for the Medical and Research Study Records of Human Volunteers

    EPA Pesticide Factsheets

    The Medical & Research Study Records of Human Volunteers System collects demographic and medical information on subjects who participate in research. Learn how this data is collected, used, access to the data, and the purpose of data collection.

  2. Medication and symptom management education program for the rehabilitation of psychiatric patients in Korea: the effects of promoting schedule on self-efficacy theory.

    PubMed

    Shon, Kyung Hee; Park, Si Sung

    2002-10-01

    An effective rehabilitation program was developed for psychiatric patients' self-management of medication and symptoms. The rehabilitation program was designed to allow the patients to understand their illness, cope with their medical regimen, and prevent a relapse by recognizing any of the symptoms when they recur. This study consisted of three phases. The first phase was to explore the extent and the specific mental health needs of psychiatric patients. Data was obtained from 82 subjects who had symptoms of a mental illness including schizophrenia, bipolar disorders, and delusional disorder. They had received medication instruction during their hospitalization. The subjects were at the time outpatients in a psychiatric hospital. In the second phase, the researchers developed an educational program focused on coping with the residual and relapse warning signs, managing the drug side effects, medication compliance, and daily routines, according to the information acquired in the first step. The developed program includes the self-efficacy method reported by Bandura, including manuals and videotapes focusing on real life situations, small group discussions, and telephone coaching. Finally, the researchers investigated the effects of this program. Thirty-eight patients were selected for this study, 18 in the experimental program and 20 as controls. The diagnoses were same as those with the first step. The results showed that the subjects who attended this educational program reported significantly more improvement in self-efficacy (p=0.014) and medication compliance (p= 0.005), and significantly less relapse warning symptom scores (p=0.000) than the controls. In conclusion, these instructional materials will be beneficial for medication and symptom management in rehabilitating psychiatric patients in Korea. In addition, the materials may be a useful psychoeducational resource for professionals in the field of clinical psychiatry.

  3. 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.

  4. The role of psychiatric and medical traditions in the discovery and description of anorexia nervosa in France, Germany, and Italy, 1873-1918.

    PubMed

    Habermas, T

    1991-06-01

    Should the national idiosyncrasies in the medical history of anorexia nervosa be attributed to differences in its prevalence or to differences in medical thinking? French, German, and Italian literature prior to World War I demonstrates that three approaches within traditions of psychiatric or medical thinking suffice to explain the national differences in reports of anorexia nervosa: minute clinical description, attentiveness to psychological facts, and attentiveness to nutrition. Furthermore, additional contributing factors are considered: general interest in neuroses, the institutional context, and the political context. As a result, historical epidemiological inferences are not warranted on the basis of the number of publications alone.

  5. 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

  6. 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.

  7. American Psychiatric Association

    MedlinePlus

    ... Foundation APA Annual Meeting Psychiatric News PsychiatryOnline Workplace Mental Health Sign In Join General Residents and Fellows Medical Students International close menu Psychiatrists Education Practice Cultural Competency Awards & Leadership Opportunities Advocacy & APAPAC Meetings ...

  8. Psychiatric liability: Part 1.

    PubMed

    Fiesta, J

    1998-07-01

    Psychiatric health care providers' liability extends from clinical cases--medication errors, misdiagnosis, etc.--to particular issues unique to the mental health setting. Part 1 discusses lawsuits common to this setting.

  9. Psychiatric liability: Part 2.

    PubMed

    Fiesta, J

    1998-08-01

    Psychiatric health care providers' liability extends from clinical cases--medication errors, misdiagnosis, etc.--to particular issues unique to the mental health care setting. Part 2 continues discussion begun in the July issue of lawsuits common to this setting.

  10. A comparison of medical record with billing diagnostic information associated with ambulatory medical care.

    PubMed Central

    Studney, D R; Hakstian, A R

    1981-01-01

    The degree of similarity between diagnostic information furnished with claims and that simultaneously entered into the medical record was estimated for 1,215 private office visits in British Columbia, Canada. For each visit, claim card and chart diagnoses were compared by having three independent internists (blinded to source and type of the data) make judgments about each diagnostic pair. The judges were highly consistent internally and their judgments were stable over time. In 40 per cent of cases chart and claims data were judged dissimilar, and in 38 per cent of cases claims data were judged more valuable as a reflection of the primary problem treated. The degree of judged similarity of chart and claims data correlated significantly and negatively with physician workload, income, and judges' preference for the billing card diagnosis. We conclude that in using claims data to determine the content of ambulatory visits, independent validation of such data may be important. PMID:7457683

  11. Accuracy of Dialysis Medical Records in Determining Patient Interest in and Suitability for Transplantation

    PubMed Central

    Huml, Anne M.; Sullivan, Catherine M.; Pencak, Julie A.; Sehgal, Ashwini R.

    2013-01-01

    Background We sought to determine the accuracy of dialysis medical records in identifying patient interest in and suitability for transplantation. Study Design Cluster randomized controlled trial Setting and Participants 167 patients recruited from 23 hemodialysis facilities. Intervention Navigators met with intervention patients to provide transplant information and assistance. Control patients continued to receive usual care. Outcomes Agreement at study initiation between medical records and (a) patient self-reported interest in transplantation and (b) study assessments of medical suitability for transplant referral. Measurements Medical record assessments, self-reports, and study assessments of patient interest in and suitability for transplantation. Results There was disagreement between medical records and patient self-reported interest in transplantation for 66 (40%) of the 167 study patients. In most of these cases, patients reported being more interested in transplantation than their medical records indicated. The study team determined that all 92 intervention patients were medically suitable for transplant referral. However, for 38 (41%) intervention patients, medical records indicated that they were not suitable. About two-thirds of these patients successfully moved forward in the transplant process. Conclusion Dialysis medical records are frequently inaccurate in determining patient interest in and suitability for transplantation. PMID:23803012

  12. 45 CFR 5b.6 - Special procedures for notification of or access to medical records.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 45 Public Welfare 1 2010-10-01 2010-10-01 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...

  13. 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…

  14. 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...

  15. 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 schedule…

  16. 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…

  17. Association between neighbourhood air pollution concentrations and dispensed medication for psychiatric disorders in a large longitudinal cohort of Swedish children and adolescents

    PubMed Central

    Bråbäck, Lennart; Åström, Daniel Oudin; Strömgren, Magnus; Forsberg, Bertil

    2016-01-01

    Objective To investigate associations between exposure to air pollution and child and adolescent mental health. Design Observational study. Setting Swedish National Register data on dispensed medications for a broad range of psychiatric disorders, including sedative medications, sleeping pills and antipsychotic medications, together with socioeconomic and demographic data and a national land use regression model for air pollution concentrations for NO2, PM10 and PM2.5. Participants The entire population under 18 years of age in 4 major counties. We excluded cohort members whose parents had dispensed a medication in the same medication group since the start date of the register. The cohort size was 552 221. Main outcome measures Cox proportional hazards models to estimate HRs and their 95% CIs for the outcomes, adjusted for individual-level and group-level characteristics. Results The average length of follow-up was 3.5 years, with an average number of events per 1000 cohort members of ∼21. The mean annual level of NO2 was 9.8 µg/m3. Children and adolescents living in areas with higher air pollution concentrations were more likely to have a dispensed medication for a psychiatric disorder during follow-up (HR=1.09, 95% CI 1.06 to 1.12, associated with a 10 µg/m3 increase in NO2). The association with NO2 was clearly present in 3 out of 4 counties in the study area; however, no statistically significant heterogeneity was detected. Conclusion There may be a link between exposure to air pollution and dispensed medications for certain psychiatric disorders in children and adolescents even at the relatively low levels of air pollution in the study regions. The findings should be corroborated by others. PMID:27259522

  18. Lessons from psychiatry and psychiatric education for medical learners and teachers.

    PubMed

    Hilty, Donald M; Srinivasan, Malathi; Xiong, Glen L; Ferranti, Jessica; Li, Su-Ting T

    2013-06-01

    Medical learners, teachers, and institutions face significant challenges in health care delivery and in training the next generation of clinicians. We propose that psychiatry offers lessons which may help improve how we take care of patients and how we teach others to care for patients. Our objective is to discuss what learners and teachers can learn from psychiatry, organized around (1) how we make decisions, (2) how we learn, and (3) how we reflect on our practice. Information from clinical care, education, neuroscience and other aspects of life (e.g. business, creativity, and research) help us on these processes. We make 'good' decisions in concert with patients and learners, by listening to their experiences, asking questions and exploring subjective and objective information. Our learning has a neurobiological basis, and is effectively furthered by personalization, reinforcement, acquisition of critical thinking skills, and assessment of our limitations and errors. Our ability to reflect is determined by attitude, skill, tolerating ambiguity or dissonance, and planning for the unexpected. These processes - in addition to knowledge and other skills - will help physicians be successful in practice, learning and teaching, research and leadership.

  19. Cancer patients' attitudes and experiences of online access to their electronic medical records: A qualitative study.

    PubMed

    Rexhepi, Hanife; Åhlfeldt, Rose-Mharie; Cajander, Åsa; Huvila, Isto

    2016-07-19

    Patients' access to their online medical records serves as one of the cornerstones in the efforts to increase patient engagement and improve healthcare outcomes. The aim of this article is to provide in-depth understanding of cancer patients' attitudes and experiences of online medical records, as well as an increased understanding of the complexities of developing and launching e-Health services. The study result confirms that online access can help patients prepare for doctor visits and to understand their medical issues. In contrast to the fears of many physicians, the study shows that online access to medical records did not generate substantial anxiety, concerns or increased phone calls to the hospital.

  20. Rapid Identification of Myocardial Infarction Risk Associated With Diabetes Medications Using Electronic Medical Records

    PubMed Central

    Brownstein, John S.; Murphy, Shawn N.; Goldfine, Allison B.; Grant, Richard W.; Sordo, Margarita; Gainer, Vivian; Colecchi, Judith A.; Dubey, Anil; Nathan, David M.; Glaser, John P.; Kohane, Isaac S.

    2010-01-01

    OBJECTIVE To assess the ability to identify potential association(s) of diabetes medications with myocardial infarction using usual care clinical data obtained from the electronic medical record. RESEARCH DESIGN AND METHODS We defined a retrospective cohort of patients (n = 34,253) treated with a sulfonylurea, metformin, rosiglitazone, or pioglitazone in a single academic health care network. All patients were aged >18 years with at least one prescription for one of the medications between 1 January 2000 and 31 December 2006. The study outcome was acute myocardial infarction requiring hospitalization. We used a cumulative temporal approach to ascertain the calendar date for earliest identifiable risk associated with rosiglitazone compared with that for other therapies. RESULTS Sulfonylurea, metformin, rosiglitazone, or pioglitazone therapy was prescribed for 11,200, 12,490, 1,879, and 806 patients, respectively. A total of 1,343 myocardial infarctions were identified. After adjustment for potential myocardial infarction risk factors, the relative risk for myocardial infarction with rosiglitazone was 1.3 (95% CI 1.1–1.6) compared with sulfonylurea, 2.2 (1.6–3.1) compared with metformin, and 2.2 (1.5–3.4) compared with pioglitazone. Prospective surveillance using these data would have identified increased risk for myocardial infarction with rosiglitazone compared with metformin within 18 months of its introduction with a risk ratio of 2.1 (95% CI 1.2–3.8). CONCLUSIONS Our results are consistent with a relative adverse cardiovascular risk profile for rosiglitazone. Our use of usual care electronic data sources from a large hospital network represents an innovative approach to rapid safety signal detection that may enable more effective postmarketing drug surveillance. PMID:20009093

  1. The relationships of sociodemographic factors, medical, psychiatric, and substance-misuse co-morbidities to neurocognition in short-term abstinent alcohol-dependent individuals.

    PubMed

    Durazzo, Timothy C; Rothlind, Johannes C; Gazdzinski, Stefan; Meyerhoff, Dieter J

    2008-09-01

    Co-morbidities that commonly accompany those afflicted with an alcohol use disorder (AUD) may promote variability in the pattern and magnitude of neurocognitive abnormalities demonstrated. The goal of this study was to investigate the influence of several common co-morbid medical conditions (primarily hypertension and hepatitis C), psychiatric (primarily unipolar mood and anxiety disorders), and substance use (primarily psychostimulant and cannabis) disorders, and chronic cigarette smoking on the neurocognitive functioning in short-term abstinent, treatment-seeking individuals with AUD. Seventy-five alcohol-dependent participants (ALC; 51+/-9 years of age; three females) completed comprehensive neurocognitive testing after approximately 1 month of abstinence. Multivariate multiple linear regression evaluated the relationships among neurocognitive variables and medical conditions, psychiatric, and substance-use disorders, controlling for sociodemographic factors. Sixty-four percent of ALC had at least one medical, psychiatric, or substance-abuse co-morbidity (excluding smoking). Smoking status (smoker or nonsmoker) and age were significant independent predictors of cognitive efficiency, general intelligence, postural stability, processing speed, and visuospatial memory after age-normed adjustment and control for estimated pre-morbid verbal intelligence, education, alcohol consumption, and medical, psychiatric, and substance-misuse co-morbidities. Results indicated that chronic smoking accounted for a significant portion of the variance in the neurocognitive performance of this middle-aged AUD cohort. The age-related findings for ALC suggest that alcohol dependence, per se, was associated with diminished neurocognitive functioning with increasing age. The study of participants who demonstrate common co-morbidities observed in AUD is necessary to fully understand how AUD, as a clinical syndrome, affects neurocognition, brain neurobiology, and their changes with

  2. [How should be a psychiatric hospital to take in and utilize the psycho-social approaches in Japan? -- From the view point of psychiatry, medical model, medical system and economical management system].

    PubMed

    Horikawa, Kohei; Horikawa, Yuriko

    2012-01-01

    The author developed argument that a cause of the present condition of our country, in which psycho-social approaches have not fully spread though its clinical efficacy has been well recognized, is in the medical institution side. Because, our psychiatric reforms over 17 years, that reduced the average duration of hospitalization from about 2156 days to 61 days, has attained by deployment of various psycho-social approaches based on "therapeutic community model" and "psychodynamic team treatment". Furthermore, it has done by the affinity, continuity and complementarities of "psychodynamic team treatment" and psychosocial approaches with following special features. That is, since psycho-social approaches is 1. techniques to acquire the social life skill and to prevent re-hospitalization, 2. the group psychotherapy by facilitating the patient's mutual help capability, 3. based on "acceptance of the disease" by "noticing the diagnosis". Even if the therapeutic orientation or assumption of the psychiatric hospital does not comprehend above all of 1-3, it is important whether it is in the same direction or not. In other words, it is the issue of the medical-economical-management system, medical model and also the kind of psychiatry that is the source of them. Our hospital is for short term hospitalization and in focus on the outpatient treatment with "psychodynamic team treatment" based on "therapeutic community model". That is why our hospital has a potential advantage to take in and utilize the psycho-social approaches. On the other hand, there is the same reason why it is difficult for the traditional psychiatric hospital for long term hospitalization with higher hierarchical "physical medicine model" based on the descriptive psychiatry. The further problem is that both psychiatric hospital staff and psycho-social therapists do not realize it. The most important issue for us is having the recognition and exploring the method not to adapt to a psychiatric hospital but

  3. 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…

  4. 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...

  5. 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...

  6. 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...

  7. 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...

  8. Special requirements of electronic medical record systems in obstetrics and gynecology.

    PubMed

    McCoy, Michael J; Diamond, Anne M; Strunk, Albert L

    2010-07-01

    There is growing recognition of the importance and potential benefit of information technology and electronic medical records in providing quality care for women. Incorporation of obstetrician-gynecologist-specific requirements by electronic medical record vendors is essential to achieve appropriate electronic medical record functionality for obstetrician-gynecologists. Obstetricians and gynecologists record and document patient care in ways that are unique to medicine. Current electronic medical record systems are often limited in their usefulness for the practice of obstetrics and gynecology because of the absence of obstetrician-gynecologist specialty-specific requirements and functions. The Certification Commission on Health Information Technology is currently the only federally recognized body for certification of electronic medical record systems. As Certification Commission on Health Information Technology expands the certification criteria for electronic medical records, the special requirements identified in this report will be used as a framework for developing obstetrician-gynecologist specialty-specific criteria to be incorporated into the Certification Commission on Health Information Technology endorsement for electronic medical records used by obstetrician-gynecologists.

  9. 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…

  10. DRUG-DRUG INTERACTION PROFILES OF MEDICATION REGIMENS EXTRACTED FROM A DE-IDENTIFIED ELECTRONIC MEDICAL RECORDS SYSTEM

    PubMed Central

    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

  11. 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

  12. Security and confidentiality in an electronic medical record.

    PubMed

    Olson, L A; Peters, S G; Stewart, J B

    1998-01-01

    The maintenance of privacy and confidentially must remain a core principle of the interaction between patients and medical staff. Traditionally, the single paper copy of the medical history has been treated with systematic handling, careful tracking, and respect for the integrity and confidentiality of the contents. The widespread availability of computerized information requires that these principles be maintained in the electronic environment. Security measures should protect sensitive data without hindering medical practice. At Mayo, we have established data security policies and standards for the handling of all electronic information. Dissemination and communication of these standards and guidelines are an ongoing challenge. Technical maneuvers can be employed to protect data integrity, identify users, and monitor compliance. Personnel policies must be updated to reflect the responsibilities and liabilities of the electronic environment. Practice efficiencies and access to clinical data must be balanced by individual responsibility and accountability for privileged patient information.

  13. Integration of a psychiatric service in a long-term charitable facility for people with intellectual disabilities: a 5-year medication survey.

    PubMed

    Ruggerini, Ciro; Guaraldi, Gian Paolo; Russo, Angela; Neviani, Vittoria; Castagnini, Augusto

    2004-01-01

    Since the implementation of a psychiatric service in a long-term facility for people with intellectual disability, the usage of psychotropic and anti-convulsant drugs has been surveyed over the 5-year period 1994-1999. At that time, although the overall prevalence rate of residents on medication was not declining significantly, a decrease in number, dosage and polypharmacy of those receiving neuroleptic drugs occurred than 1994. A reduction also resulted among the in-patients prescribed anxiolytic preparations, despite a relative increase in their mean daily intake. Anti-convulsant drugs climbed slightly during the same interval with a parallel increase in the mean daily dosage. A retrospective comparison of current findings to prevalence, dosage and type of psychoactive medications dispensed 10 years previously in 1989 revealed no trend towards drug rationalisation. Until interdisciplinary training programmes as well as effective community services combining disability and mental health needs are forthcoming, a therapeutic approach involving early psychiatric inputs may contribute to ensure a more rational prescribing practice for long-stay adults with intellectual disability who are referred for neuro-psychiatric consultation.

  14. Implementation of an optical disk system for medical record storage.

    PubMed

    Mahoney, M E

    1990-09-01

    MARS was a joint developmental effort between Maine Medical Center and Advanced Healthcare Systems, Inc. It has taken nearly three years to get the system (hardware, software, and staff) to a point where it can now meet daily production requirements. This project was truly unique, so there was no opportunity to learn from the experiences of others. The optical disk system has been an attractive solution to some of the problems experienced at Maine Medical Center. The result was worth the effort in terms of both dollars and other less quantifiable benefits that have had a positive impact on patient care.

  15. A software system to collect expert relevance ratings of medical record items for specific clinical tasks.

    PubMed

    Harvey, H Benjamin; Krishnaraj, Arun; Alkasab, Tarik K

    2014-02-28

    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.

  16. Records access and management on closure of a medical practice.

    PubMed

    Carter, David J

    2015-07-20

    Despite uneven regulation, health practitioners registered with the Australian Health Practitioner Regulation Agency have immediate and continuing obligations to patients when contemplating practice closure. Recent enforcement actions by regulators highlight the importance of knowledge and compliance with requirements relating to record management.

  17. Can multilingual machine translation help make medical record content more comprehensible to patients?

    PubMed

    Zeng-Treitler, Qing; Kim, Hyeoneui; Rosemblat, Graciela; Keselman, Alla

    2010-01-01

    With the development of electronic personal health records, more patients are gaining access to their own medical records. However, comprehension of medical record content remains difficult for many patients. Because each record is unique, it is also prohibitively costly to employ human translators to solve this problem. In this study, we investigated whether multilingual machine translation could help make medical record content more comprehensible to patients who lack proficiency in the language of the records. We used a popular general-purpose machine translation tool called Babel Fish to translate 213 medical record sentences from English into Spanish, Chinese, Russian and Korean. We evaluated the comprehensibility and accuracy of the translation. The text characteristics of the incorrectly translated sentences were also analyzed. In each language, the majority of the translations were incomprehensible (76% to 92%) and/or incorrect (77% to 89%). The main causes of the translation are vocabulary difficulty and syntactical complexity. A general-purpose machine translation tool like the Babel Fish is not adequate for the translation of medical records; however, a machine translation tool can potentially be improved significantly, if it is trained to target certain narrow domains in medicine.

  18. Sleep paralysis and trauma, psychiatric symptoms and disorders in an adult African American population attending primary medical care.

    PubMed

    Mellman, Thomas A; Aigbogun, Notalelomwan; Graves, Ruth Elaine; Lawson, William B; Alim, Tanya N

    2008-01-01

    The occurrence of sleep paralysis (SP) absent narcolepsy appears to not be uncommon in African Americans and probably other non-European groups. Prior research has linked SP to trauma and psychiatric disorders and suggested a specific relationship to panic disorder in African Americans. The objective of our study was to evaluate relationships of SP with trauma, concurrent psychiatric symptoms and lifetime psychiatric diagnoses in an adult African American population recruited from primary care. Cross sectional study with surveys and diagnostic interviews; Patients attending primary care clinics filled out a survey that determined the 6 month prevalence and associated features of SP, a panic disorder screen, the self-rated Hamilton Depression Scale, and an inventory of trauma exposure. A subset of trauma-exposed participants (N = 142) received comprehensive diagnostic interviews that incorporated the Structured Clinical Interview for DSM-IV and the Clinician Assessed PTSD Scale. Four hundred and forty-one adults participated (mean age-40.0 SD = 13.3, 68% female, 95% African American). Fourteen percent endorsed recent SP. In approximately 1/3 of those with SP, episodes also featured panic symptoms. SP was strongly associated with trauma history, and concurrent anxiety and mood symptoms. SP was not associated with specific psychiatric disorders other than lifetime (but not current) alcohol or substance use disorders. Our findings suggest that SP is not uncommon in adult African Americans and is associated with trauma and concurrent distress but not with a specific psychiatric diagnosis.

  19. 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…

  20. Deep brain stimulation for psychiatric disorders: where we are now.

    PubMed

    Cleary, Daniel R; Ozpinar, Alp; Raslan, Ahmed M; Ko, Andrew L

    2015-06-01

    Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned. Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry. This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.

  1. 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

  2. Co-occurring amphetamine use and associated medical and psychiatric comorbidity among opioid-dependent adults: results from the clinical Trials Network

    PubMed Central

    Pilowsky, Daniel J; Wu, Li-Tzy; Burchett, Bruce; Blazer, Dan G; Woody, George E; Ling, Walter

    2011-01-01

    Background In response to the rising rate of treatment admissions related to illicit use of amphetamines (eg, methamphetamine), we examined the prevalence of amphetamine use among treatment-seeking, opioid-dependent adults, explored whether amphetamine users were as likely as nonamphetamine users to enroll in opioid-dependence treatment trials, and determined whether amphetamine users manifested greater levels of medical and psychiatric comorbidity than nonusers. Methods The sample included 1257 opioid-dependent adults screened for participation in three-multisite studies of the National Drug Abuse Treatment Clinical Trials Network (CTN001-003), which studied the effectiveness of buprenorphine for opioid detoxification under varying treatment conditions. Patients were recruited from 23 addiction treatment programs across the US. Medical and psychiatric comorbidity were examined by past-month amphetamine use (current vs former) and route of administration. Five mutually exclusive groups were examined, ie, nonusers, current amphetamine injectors, current amphetamine noninjectors, former amphetamine injectors, and former amphetamine noninjectors. Results Of the sample (n = 1257), 22.3% had a history of regular amphetamine use. Of the 280 amphetamine users, 30.3% reported injection as their primary route. Amphetamine users were more likely than nonusers to be white and use more substances. Amphetamine users were as likely as nonusers to enroll in treatment trials. Bivariate analyses indicated elevated rates of psychiatric problems (depression, anxiety, hallucinations, cognitive impairment, violence, suicidal thoughts/attempts) and medical illnesses (dermatological, hepatic, cardiovascular, respiratory, neurological, seizure, allergy conditions) among amphetamine users. After adjusting for demographic variables and lifetime use of other substances: current amphetamine users and former injectors showed an increased likelihood of having medical illnesses and

  3. Development of Markup Language for Medical Record Charting: A Charting Language.

    PubMed

    Jung, Won-Mo; Chae, Younbyoung; Jang, Bo-Hyoung

    2015-01-01

    Nowadays a lot of trials for collecting electronic medical records (EMRs) exist. However, structuring data format for EMR is an especially labour-intensive task for practitioners. Here we propose a new mark-up language for medical record charting (called Charting Language), which borrows useful properties from programming languages. Thus, with Charting Language, the text data described in dynamic situation can be easily used to extract information.

  4. Impact of Randomization, Clinic Visits, and Medical and Psychiatric Cormorbidities on Continuous Positive Airway Pressure Adherence in Obstructive Sleep Apnea

    PubMed Central

    Budhiraja, Rohit; Kushida, Clete A.; Nichols, Deborah A.; Walsh, James K.; Simon, Richard D.; Gottlieb, Daniel J.; Quan, Stuart F.

    2016-01-01

    visits approach. Citation: Budhiraja R, Kushida CA, Nichols DA, Walsh JK, Simon RD, Gottlieb DJ, Quan SF. Impact of randomization, clinic visits, and medical and psychiatric cormorbidities on continuous positive airway pressure adherence in obstructive sleep apnea. J Clin Sleep Med 2016;12(3):333–341. PMID:26518698

  5. 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

  6. The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

    PubMed Central

    Davaridolatabadi, Nasrin; Sadoughi, Farahnaz; Meidani, Zahra; Shahi, Mehraban

    2013-01-01

    Introduction: Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since physicians play a crucial role in medical record documentation, the researchers intend to examine the effect of educational intervention on physicians’ performance and knowledge about principles of medical diagnosis recording among residents in Hormozgan University of Medical Sciences(HUMS). Methods: This quasi-experimental study was conducted in 2010 on 40 specialty residents (from internal medicine, obstetrics and gynecology, pediatrics, anesthesiology and surgery specialties) in Hormozgan University of Medical Sciences. During a workshop, guidelines for recording diagnostic information related to given specialty were taught. Before and after the intervention, five medical records from each resident were selected to assess physician performance about chart documentation. Using a questionnaire, physicians’ knowledge was investigated before and after intervention. Data were analyzed through one-way ANOVA test. Results: Change in physicians’ knowledge before and after education was not statistically significant (p = 0.15). Residents’ behavior did not have statistically significant changes during three phases of the study. Conclusion: Diversity of related factors which contributes to the quality of documentation compels portfolio of strategies to enhance medical charting. Employing combination of best practice efforts including educating physicians from the beginning of internship and applying targeted strategy focus on problematic areas and existing gap may enhance physicians’ behavior about chart documentation. PMID:24167386

  7. 78 FR 55114 - Access to Employee Exposure and Medical Records; Extension of the Office of Management and Budget...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-09-09

    ... Occupational Safety and Health Administration Access to Employee Exposure and Medical Records; Extension of the... Exposure and Medical Records Standard (29 CFR 1910.1020). DATES: Comments must be submitted (postmarked... to employee exposure monitoring data and medical records. This regulation does not require...

  8. 33 CFR 150.604 - Who controls access to medical monitoring and exposure records?

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 33 Navigation and Navigable Waters 2 2013-07-01 2013-07-01 false Who controls access to medical monitoring and exposure records? 150.604 Section 150.604 Navigation and Navigable Waters COAST GUARD... Health Safety and Health (general) § 150.604 Who controls access to medical monitoring and...

  9. Optimizing Inpatient Urine Culture Ordering Practices Using the Electronic Medical Record: A Pilot Study.

    PubMed

    Shirley, Daniel; Scholtz, Harry; Osterby, Kurt; Musuuza, Jackson; Fox, Barry; Safdar, Nasia

    2017-04-01

    A prospective quasi-experimental before-and-after study of an electronic medical record-anchored intervention of embedded education on appropriate urine culture indications and indication selection reduced the number of urine cultures ordered for catheterized patients at an academic medical center. This intervention could be a component of CAUTI-reduction bundles. Infect Control Hosp Epidemiol 2017;38:486-488.

  10. A Study to Delineate Roles and Functions of Medical Record Personnel: Final Report.

    ERIC Educational Resources Information Center

    American Medical Record Association, Chicago, IL.

    In order to be able to comply, and to be able to document their compliance, with federal legislation regarding health occupations education and discriminatory practices, the American Medical Record Association conducted a study to see if a data base could be built to validate proficiency tests for medical personnel. The report was prepared to…

  11. The patient's photograph in the medical record as a diagnostic tool.

    PubMed

    Golan-Cohen, Avivit; Horn, Oded; Sive, Philip H; Vinker, Shlomo

    2008-12-01

    Two case reports are presented: one of acromegaly and the other of hyperthyroidism. Previous photographs of the patients that appeared in their military medical record were of considerable assistance in making the correct diagnoses. When "smart cards" are issued in the future, inclusion of a photograph as an integral part of the patient's medical information should be considered.

  12. 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…

  13. 29 CFR 1904.9 - Recording criteria for cases involving medical removal under OSHA standards.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... surveillance requirements of an OSHA standard, you must record the case on the OSHA 300 Log. (b) Implementation—(1) How do I classify medical removal cases on the OSHA 300 Log? You must enter each medical removal case on the OSHA 300 Log as either a case involving days away from work or a case involving...

  14. 29 CFR 1904.9 - Recording criteria for cases involving medical removal under OSHA standards.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... surveillance requirements of an OSHA standard, you must record the case on the OSHA 300 Log. (b) Implementation—(1) How do I classify medical removal cases on the OSHA 300 Log? You must enter each medical removal case on the OSHA 300 Log as either a case involving days away from work or a case involving...

  15. A cross-sectional prospective study of seclusion, restraint and involuntary medication in acute psychiatric wards: patient, staff and ward characteristics

    PubMed Central

    2010-01-01

    Background Previous research on mental health care has shown considerable differences in use of seclusion, restraint and involuntary medication among different wards and geographical areas. This study investigates to what extent use of seclusion, restraint and involuntary medication for involuntary admitted patients in Norwegian acute psychiatric wards is associated with patient, staff and ward characteristics. The study includes data from 32 acute psychiatric wards. Methods Multilevel logistic regression using Stata was applied with data from 1016 involuntary admitted patients that were linked to data about wards. The sample comprised two hierarchical levels (patients and wards) and the dependent variables had two values (0 = no use and 1 = use). Coercive measures were defined as use of seclusion, restraint and involuntary depot medication during hospitalization. Results The total number of involuntary admitted patients was 1214 (35% of total sample). The percentage of patients who were exposed to coercive measures ranged from 0-88% across wards. Of the involuntary admitted patients, 424 (35%) had been secluded, 117 (10%) had been restrained and 113 (9%) had received involuntary depot medication at discharge. Data from 1016 patients could be linked in the multilevel analysis. There was a substantial between-ward variance in the use of coercive measures; however, this was influenced to some extent by compositional differences across wards, especially for the use of restraint. Conclusions The substantial between-ward variance, even when adjusting for patients' individual psychopathology, indicates that ward factors influence the use of seclusion, restraint and involuntary medication and that some wards have the potential for quality improvement. Hence, interventions to reduce the use of seclusion, restraint and involuntary medication should take into account organizational and environmental factors. PMID:20370928

  16. 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

  17. 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.

  18. 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

  19. Medical Education and the Pharmaceutical Industry: A Review of Ethical Guidelines and Their Implications for Psychiatric Training

    ERIC Educational Resources Information Center

    Geppert, Cynthia M. A.

    2007-01-01

    Objective: This article reviews and summarizes eight ethical guidelines of major professional organizations regarding the pharmaceutical industry's role in the psychiatric education of trainees. Method: The author conducted a literature review of research and guidelines pertaining to the pharmaceutical industry's relationship to trainees, with…

  20. Psychiatric illness in inpatients with neurological disorders: patients' views on discussion of emotional problems with neurologists.

    PubMed Central

    Bridges, K W; Goldberg, D P

    1984-01-01

    The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient's physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients. PMID:6434026

  1. Medical records for animals used in research, teaching, and testing: public statement from the American College of Laboratory Animal Medicine.

    PubMed

    Field, Karl; Bailey, Michele; Foresman, Larry L; Harris, Robert L; Motzel, Sherri L; Rockar, Richard A; Ruble, Gaye; Suckow, Mark A

    2007-01-01

    Medical records are considered to be a key element of a program of adequate veterinary care for animals used in research, teaching, and testing. However, prior to the release of the public statement on medical records by the American College of Laboratory Animal Medicine (ACLAM), the guidance that was available on the form and content of medical records used for the research setting was not consistent and, in some cases, was considered to be too rigid. To address this concern, ACLAM convened an ad hoc Medical Records Committee and charged the Committee with the task of developing a medical record guideline that was based on both professional judgment and performance standards. The Committee provided ACLAM with a guidance document titled Public Statements: Medical Records for Animals Used in Research, Teaching, and Testing, which was approved by ACLAM in late 2004. The ACLAM public statement on medical records provides guidance on the definition and content of medical records, and clearly identifies the Attending Veterinarian as the individual who is charged with authority and responsibility for oversight of the institution's medical records program. The document offers latitude to institutions in the precise form and process used for medical records but identifies typical information to be included in such records. As a result, the ACLAM public statement on medical records provides practical yet flexible guidelines to assure that documentation of animal health is performed in research, teaching, and testing situations.

  2. Occupational Safety and Health Administration--Access to employee exposure and medical records. Final rule.

    PubMed

    1980-05-23

    This final occupational safety and health standard, promulgated today as a revised 29 CFR 1910.20, provides for employee, designated representative, and OSHA access to employer-maintained exposure and medical records relevant to employees exposed to toxic substances and harmful physical agents. Access is also assured to employer analyses using exposure and medical records. The final standard requires long term preservation of these records, contains provisions concerning informing employees of their rights under the standard, and includes provisions protective of trade secret information.

  3. Performance analysis of distributed and centralized models for electronic medical record exchanges.

    PubMed

    Huang, Ean-Wen; Lee, Chiung-San; Jiang, Wey-Wen; Chiou, Shwu-Fen; Liu, Fei-Ying; Liou, Der-Ming

    2007-01-01

    Electronic medical record exchanges can save time and reduce cost by eliminating redundant data and typing errors. The major steps of record exchange consist of querying information from database, encoding data into messages, and sending and decoding messages. Three medical-record-exchange models were proposed in the past, including the distributed, centralized, and indexed models. In this paper, the queuing theory is applied to evaluate the performance of the three models. We estimate the service time for each queue of the CPU, database and network, and predict the response time, probable bottlenecks and system capacities of each model.

  4. Patients, privacy and trust: patients' willingness to allow researchers to access their medical records.

    PubMed

    Damschroder, Laura J; Pritts, Joy L; Neblo, Michael A; Kalarickal, Rosemarie J; Creswell, John W; Hayward, Rodney A

    2007-01-01

    The federal Privacy Rule, implemented in the United States in 2003, as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), created new restrictions on the release of medical information for research. Many believe that its restrictions have fallen disproportionately on researchers prompting some to call for changes to the Rule. Here we ask what patients think about researchers' access to medical records, and what influences these opinions. A sample of 217 patients from 4 Veteran Affairs (VA) facilities deliberated in small groups at each location with the opportunity to question experts and inform themselves about privacy issues related to medical records research. After extensive deliberation, these patients were united in their inclination to share their medical records for research. Yet they were also united in their recommendations to institute procedures that would give them more control over whether and how their medical records are used for research. We integrated qualitative and quantitative results to derive a better understanding of this apparent paradox. Our findings can best be presented as answers to questions related to five dimensions of trust: Patients' trust in VA researchers was the most powerful determinant of the kind of control they want over their medical records. More specifically, those who had lower trust in VA researchers were more likely to recommend a more stringent process for obtaining individual consent. Insights on the critical role of trust suggest actions that researchers and others can take to more fully engage patients in research.

  5. Extracting Concepts Related to Homelessness from the Free Text of VA Electronic Medical Records.

    PubMed

    Gundlapalli, Adi V; Carter, Marjorie E; Divita, Guy; Shen, Shuying; Palmer, Miland; South, Brett; Durgahee, B S Begum; Redd, Andrew; Samore, Matthew

    2014-01-01

    Mining the free text of electronic medical records (EMR) using natural language processing (NLP) is an effective method of extracting information not always captured in administrative data. We sought to determine if concepts related to homelessness, a non-medical condition, were amenable to extraction from the EMR of Veterans Affairs (VA) medical records. As there were no off-the-shelf products, a lexicon of terms related to homelessness was created. A corpus of free text documents from outpatient encounters was reviewed to create the reference standard for NLP training and testing. V3NLP Framework was used to detect instances of lexical terms and was compared to the reference standard. With a positive predictive value of 77% for extracting relevant concepts, this study demonstrates the feasibility of extracting positively asserted concepts related to homelessness from the free text of medical records.

  6. Using an iconic language to improve access to electronic medical records in general medicine.

    PubMed

    Simon, Christian; Hassler, Sylvain; Beuscart-Zephir, Marie-Catherine; Favre, Madeleine; Venot, Alain; Duclos, Catherine; Lamy, Jean-Baptiste

    2014-01-01

    Physicians have difficulties to access and analyse information in a medical record. In a previous work on drug databanks, we have shown that with an iconic language as VCM, an icon-based presentation can help physicians to access medical information. Our objective, herein, is to study whether VCM can be used in an electronic medical record for facilitating physician access in general practice. We identify the data and the functionalities of an electronic medical record that could benefit from VCM icons representing clinical findings, patient history, etc. We also present a preliminary evaluation of this new icon-focused interface. We conclude by discussing the results like the assessment of the user's satisfaction and pointing out the importance of coding data.

  7. Method and system for determining precursors of health abnormalities from processing medical records

    DOEpatents

    None, None

    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.

  8. Inferring Clinical Workflow Efficiency via Electronic Medical Record Utilization.

    PubMed

    Chen, You; Xie, Wei; Gunter, Carl A; Liebovitz, David; Mehrotra, Sanjay; Zhang, He; Malin, Bradley

    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.

  9. 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

  10. From medical record to patient record through electronic data interchange (EDI).

    PubMed

    Kinkhorst, O M; Lalleman, A W; Hasman, A

    1996-07-01

    In this contribution the role of Electronic Data Interchange (EDI) for patient records is discussed. It is our opinion that unlimited access to patient records of different care provides is not a wise thing to do and may even not be acceptable legally. The exchange of EDI messages may be a solution in that the relevant information is exchanged on a need to know basis under the responsibility of the care provider that generated the information. The state of the art with respect to the availability of EDI messages in Europe is presented.

  11. Psychiatric Aspects of Renal Transplantation

    PubMed Central

    Chaturvedi, S.K.; Pant, V.L.N.

    1985-01-01

    SUMMARY This report pertains to the psychiatric problems in renal transplant recipients and its socio-demographic correlations. 50 male recipient subjects with a post-transplant period ranging from six months to six years were evaluated through tape recorded interviews to study their pre and post-operative emotional reactions. A psychiatric examination was performed by two psychiatrists and a diagnosis given wherever necessary. On examination 46% of cases had identifiable psychiatric problems, mainly Anxiety Neurosis (18%), Depressive Neurosis (18%), Adjustment Reactions (10%). Non-organic (Psychogenic) pain, excessive somatic concern and personality changes were also noticed in some. The psychiatric illness was significantly more amongst unmarried (P < .05) and higher education group (P < .02). Other variables had no significant correlation with the psychiatric illness. None had psychoses or a major depressive disorder. Thus, psychiatric problems are present in particular groups of transplant recipients and are usually neurotic in nature and would require psychiatric help regarding these. PMID:21927072

  12. Medical device integration: CIOs must bridge the digital divide between devices and electronic medical records.

    PubMed

    Raths, David

    2009-02-01

    To get funding approved for medical device integration, ClOs suggest focusing on specific patient safety or staff efficiency pain points. Organizations that make clinical engineering part of their IT team report fewer chain-of-command issues. It also helps IT people understand the clinical goals because the engineering people have been working closely with clinicians for years. A new organization has formed to work on collaboration between clinical engineers and IT professionals. For more information, go to www.ceitcollaboration.org. ECRI Institute has written a guide to handling the convergence of medical technology and hospital networks. Its "Medical Technology for the IT Professional: An Essential Guide for Working in Today's Healthcare Setting" also details how IT professionals can assist hospital technology planning and acquisition, and provide ongoing support for IT-based medical technologies. For more information, visit www.ecri.org/ITresource.

  13. Installing and Implementing a Computer-based Patient Record System in Sub-Saharan Africa: The Mosoriot Medical Record System

    PubMed Central

    Rotich, Joseph K.; Hannan, Terry J.; Smith, Faye E.; Bii, John; Odero, Wilson W.; Vu, Nguyen; Mamlin, Burke W.; Mamlin, Joseph J.; Einterz, Robert M.; Tierney, William M.

    2003-01-01

    The authors implemented an electronic medical record system in a rural Kenyan health center. Visit data are recorded on a paper encounter form, eliminating duplicate documentation in multiple clinic logbooks. Data are entered into an MS-Access database supported by redundant power systems. The system was initiated in February 2001, and 10,000 visit records were entered for 6,190 patients in six months. The authors present a summary of the clinics visited, diagnoses made, drugs prescribed, and tests performed. After system implementation, patient visits were 22% shorter. They spent 58% less time with providers (p < 0.001) and 38% less time waiting (p = 0.06). Clinic personnel spent 50% less time interacting with patients, two thirds less time interacting with each other, and more time in personal activities. This simple electronic medical record system has bridged the “digital divide.” Financial and technical sustainability by Kenyans will be key to its future use and development. PMID:12668697

  14. Agreement between maternal interview- and medical record-based gestational age.

    PubMed

    Hakim, R B; Tielsch, J M; See, L C

    1992-09-01

    Agreement between maternal interview- and medical record-based gestational age was assessed by using data from a case-control study of childhood strabismus. The sample consisted of 383 cases of strabismus and their age-matched controls, diagnosed between 1985 and 1986 in Baltimore, Maryland, who were under age 7 years when diagnosed. Medical record-based gestational age was derived, in order of priority, from early ultrasound examination, time from the last menstrual period, pediatric examination, and obstetric examination. The intraclass correlation coefficient, kappa, and mean difference were used to compare agreement between maternal interview- and medical record-based gestational age by maternal and pregnancy characteristics and characteristics related to study design. Overall, 86 percent of mothers were within 2 weeks of the gestational age reported in the medical record. The intraclass correlation coefficient comparing maternal and medical record-based gestational age was 0.83 (95% confidence interval 0.80-0.86). Agreement was positively associated with shorter length of recall, low birth order, and having a neonatal illness related to prematurity. Agreement was poor among mothers of healthy preterm infants. There was a weak positive association between recall and some sociodemographic covariates. There was greater misclassification of prematurity in the controls than in the cases. The results suggest that, in general, women recall gestational age well, which supports the use of gestational age derived from maternal interviews.

  15. Problem focused knowledge navigation: implementing the problem focused medical record and the O-HEAP note.

    PubMed

    Meyers, K C; Miller, H J; Naeymi-Rad, F

    1998-01-01

    The current organization of most Computerized Medical Records (CMR) is based on the Problem Oriented Medical Record (POMR) and the SOAP (Subjective, Objective, Assessment and Plan) note. The organizational structure of the POMR and especially the SOAP note, does not allow for optimal use of computer capabilities in the follow up note. Since follow up visits are the most common office visit by far, this is a major flaw in the CMR. The authors propose a Problem Focused Medical Record and the OHEAP (Orientation, History, Exam, Assessment and Plan) note to resolve this problem. OHEAP starts with a powerful orientation structure that brings forward the timeline, last Assessment and Plan, and Plan Results for each problem along with the patient's historical tables as the starting point of every follow up visit. The Assessment and Plan portion brings problem specific differential diagnoses and their workups along with other relevant tables such as expert systems, treatments, instructions, medical literature or pathways. This leads to Problem Focused Knowledge Navigation that brings powerful efficiencies to the CMR. By recognizing the true workflow in the longitudinal diagnosis and management of any medical problem, the efficiency of the CMR is maximized. OHEAP allows for optimal use of both personal and external data elements in the medical record. Its powerful orientation attributes minimize the time spent in analyzing the current status of the problem while its connections to problem specific databases help resolve the problem.

  16. 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%.

  17. Intelligent technique for knowledge reuse of dental medical records based on case-based reasoning.

    PubMed

    Gu, Dong-Xiao; Liang, Chang-Yong; Li, Xing-Guo; Yang, Shan-Lin; Zhang, Pei

    2010-04-01

    With the rapid development of both information technology and the management of modern medical regulation, the generation of medical records tends to be increasingly intelligent. In this paper, Case-Based Reasoning is applied to the process of generating records of dental cases. Based on the analysis of the features of dental records, a case base is constructed. A mixed case retrieval method (FAIES) is proposed for the knowledge reuse of dental records by adopting Fuzzy Mathematics, which improves similarity algorithm based on Euclidian-Lagrangian Distance, and PULL & PUSH weight adjustment strategy. Finally, an intelligent system of dental cases generation (CBR-DENT) is constructed. The effectiveness of the system, the efficiency of the retrieval method, the extent of adaptation and the adaptation efficiency are tested using the constructed case base. It is demonstrated that FAIES is very effective in terms of reducing the time of writing medical records and improving the efficiency and quality. FAIES is also proven to be an effective aid for diagnoses and provides a new idea for the management of medical records and its applications.

  18. Psychiatric diagnosis, psychiatric power and psychiatric abuse.

    PubMed Central

    Szasz, T

    1994-01-01

    Psychiatric abuse, such as we usually associate with practices in the former Soviet Union, is related not to the misuse of psychiatric diagnoses, but to the political power intrinsic to the social role of the psychiatrist in totalitarian and democratic societies alike. Some reflections are offered on the modern, therapeutic state's proclivity to treat adults as patients rather than citizens, disjoin rights from responsibilities, and thus corrupt the language of political-philosophical discourse. PMID:7996558

  19. Challenges of Self-Reported Medical Conditions and Electronic Medical Records Among Members of a Large Military Cohort

    DTIC Science & Technology

    2008-06-05

    29.7 99.6 Manic - depressive disorder 0.9 (0.8, 0.9) 2.1 (2.0, 2.3) 1.9 11.8 98.7 Hepatitis C 0.8 (0.7, 0.9) 0.2 (0.2, 0.3) 0.1 25.4 99.6 Coronary...relatively common acute or transient medical conditions were migraine headaches and depression . Relatively common chronic medical conditions were...recorded data was consistently lower than prevalence based on self- report for most conditions, with the exception of chronic bronchitis, manic

  20. Overcoming Electronic Medical Record Challenges on the Obstetrics and Gynecology Clerkship.

    PubMed

    Buery-Joyner, Samantha D; Dalrymple, John L; Abbott, Jodi F; Craig, LaTasha B; Forstein, David A; Graziano, Scott C; Hampton, Brittany S; Hopkins, Laura; Page-Ramsey, Sarah M; Pradhan, Archana; Wolf, Abigail; Mckenzie, Margaret L

    2015-09-01

    This article, for the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, supplies educators with a review of best practices regarding incorporation of the electronic medical record (EMR) into undergraduate medical education. The unique circumstances of the obstetrics and gynecology clerkship require specific attention as it pertains to medical student use of the EMR. An outline of the regulatory requirements and authoritative body recommendations provides some guidance for implementation in the undergraduate medical education setting. A review of the basic framework for development of an EMR curriculum and examples of curricular innovations published in the literature offers solutions for obstacles that may be encountered by students and medical educators.

  1. Medical assistants' roles in electronic health record processes in primary care practices: the untold story.

    PubMed

    Adewale, Victoria; Anthony, David; Borkan, Jeffery

    2014-01-01

    The role of the medical assistant has been undervalued in the past. Many publications have detailed the integral role of the nursing staff and physicians, but the medical assistant role has come last in formal recognition. As healthcare settings move toward a more Patient-Centered Medical Home (PCMH) model, the attitudes of this model will need to be adopted, two of which are team-based care and adoption of the electronic health record (EHR). As the EHR continues to gain more traction in healthcare, a thorough understanding of it, by everyone, will be vital for its success. In this article, the medical assistant's relationship with the EHR is outlined through qualitative interviews and observations with medical assistants in PCMH programs. The data describe diverse EHR experiences and how these experiences are influenced by and reflected in workflow issues, training, patient care, and an expanding role of the medical assistant.

  2. Abortion and psychiatric practice.

    PubMed

    Stotland, Nada L

    2003-03-01

    The subject of abortion is fraught with politics, emotions, and misinformation. A widespread practice reaching far back in history, abortion is again in the news. Psychiatry sits at the intersection of the religious, ethical, psychological, sociological, medical, and legal facets of the abortion issue. Although the religions that forbid abortion are more prominent in the media, many religions have more liberal approaches. While the basic right to abortion has been upheld by the U.S. Supreme Court, several limitations have been permitted, including parental notification or consent (with the possibility of judicial bypass) for minors, waiting periods, and mandatory provision of certain, sometimes biased, information. Before the Roe v. Wade decision legalizing abortion in 1973, many women were maimed or killed by illegal abortions, and psychiatrists were sometimes asked to certify that abortions were justified on psychiatric grounds. Currently, there are active attempts to convince the public and women considering abortion that abortion frequently has negative psychiatric consequences. This assertion is not borne out by the literature: the vast majority of women tolerate abortion without psychiatric sequelae. The psychiatric outcome of abortion is best when patients are able to make autonomous, supported decisions. Psychiatrists need to know the medical and psychiatric facts about abortion. Psychiatrists can then help patients prevent unwanted pregnancies, make informed decisions consonant with their own values and circumstances when they become pregnant, and find appropriate social and medical resources whatever their decisions may be.

  3. 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

  4. 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?

  5. The Psychiatric Disorders of Childhood.

    ERIC Educational Resources Information Center

    Shaw, Charles R.; Lucas, Alexander R.

    A general textbook on the psychiatric disorders of childhood, the book is intended to be an introductory text for students and practitioners working with children (such as psychiatric and pediatric residents and psychologists, teachers, medical students). The genesis of mental illness is discussed in terms of the contributions of heredity and the…

  6. [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.

  7. Measurement of Psychiatric Treatment Adherence

    PubMed Central

    Sajatovic, Martha; Velligan, Dawn; Weiden, Peter J.; Valenstein, Marcia; Ogedegbe, Gbenga

    2014-01-01

    Objective Nonadherence to medications for mental disorders substantially limits treatment effectiveness and results in higher rates of relapse, hospitalization, and disability. Accurate measurement of medication adherence is important not only in adherence research, but also in clinical trials in which medications are being evaluated, and in clinical practice where failure to detect nonadherence results in premature medication changes, unnecessary polypharmacy, and greater likelihoods of functional deteriorations and hospitalizations. This is a review of psychiatric treatment adherence methods and measures arising from a meeting on “Methodological Challenges in Psychiatric Treatment Adherence Research” held on September 27-28, 2007 in Bethesda, MD and organized by the National Institute of Mental Health (NIMH). Methods This paper reviews the range of modalities currently available for assessing adherence behavior including pill counts, pharmacy records, technology-assisted monitoring, biological assays, and a range of self-report and interviewer-rated scales. Measures of adherence attitudes are also reviewed. Results Each of the adherence measures described are imperfect estimates of actual medication ingestion but each provides informative estimates of adherence or the attitudinal factors associated with adherence. Measure selection depends on a range of factors including the patient sample, the context in which the measure is being used, and the clinical outcomes expected from various levels of nonadherence. The use of multiple measures of adherence is encouraged to balance the limitations of individual measures. Conclusion While adherence assessment has become increasingly sophisticated in recent years there remains a need for refinement and expansion on currently available methods and measures. PMID:21109048

  8. Self-report versus Medical Records for Assessing Cancer-Preventive Services Delivery

    PubMed Central

    Ferrante, Jeanne M.; Ohman-Strickland, Pamela; Hahn, Karissa A.; Hudson, Shawna V.; Shaw, Eric K.; Crosson, Jesse C.; Crabtree, Benjamin F.

    2010-01-01

    Accurate measurement of cancer-preventive behaviors is important for quality improvement, research studies, and public health surveillance. Findings differ, however, depending on whether patient self-report or medical records are used as the data source. We evaluated concordance between patient self-report and medical records on risk factors, cancer screening, and behavioral counseling among primary care patients. Data from patient surveys and medical records were compared from 742 patients in 25 New Jersey primary care practices participating at baseline in SCOPE (supporting colorectal cancer outcomes through participatory enhancements), an intervention trial to improve colorectal cancer screening in primary care offices. Sensitivity, specificity, and rates of agreement describe concordance between self-report and medical records for risk factors (personal or family history of cancer, smoking), cancer screening (breast, cervical, colorectal, prostate), and counseling (cancer screening recommendations, diet or weight loss, exercise, smoking cessation). Rates of agreement ranged from 41% (smoking cessation counseling) to 96% (personal history of cancer). Cancer screening agreement ranged from 61% (Pap and prostate-specific antigen) to 83% (colorectal endoscopy) with self-report rates greater than medical record rates. Counseling was also reported more frequently by self-report (83% by patient self-report versus 34% by medical record for smoking cessation counseling). Deciding which data source to use will depend on the outcome of interest, whether the data is used for clinical decision making, performance tracking, or population surveillance; the availability of resources; and whether a false positive or a false negative is of more concern. PMID:18990740

  9. A study on agent-based secure scheme for electronic medical record system.

    PubMed

    Chen, Tzer-Long; Chung, Yu-Fang; Lin, Frank Y S

    2012-06-01

    Patient records, including doctors' diagnoses of diseases, trace of treatments and patients' conditions, nursing actions, and examination results from allied health profession departments, are the most important medical records of patients in medical systems. With patient records, medical staff can instantly understand the entire medical information of a patient so that, according to the patient's conditions, more accurate diagnoses and more appropriate in-depth treatments can be provided. Nevertheless, in such a modern society with booming information technologies, traditional paper-based patient records have faced a lot of problems, such as lack of uniform formats, low data mobility, slow data transfer, illegible handwritings, enormous and insufficient storage space, difficulty of conservation, being easily damaged, and low transferability. To improve such drawbacks, reduce medical costs, and advance medical quality, paper-based patient records are modified into electronic medical records and reformed into electronic patient records. However, since electronic patient records used in various hospitals are diverse and different, in consideration of cost, it is rather difficult to establish a compatible and complete integrated electronic patient records system to unify patient records from heterogeneous systems in hospitals. Moreover, as the booming of the Internet, it is no longer necessary to build an integrated system. Instead, doctors can instantly look up patients' complete information through the Internet access to electronic patient records as well as avoid the above difficulties. Nonetheless, the major problem of accessing to electronic patient records cross-hospital systems exists in the security of transmitting and accessing to the records in case of unauthorized medical personnels intercepting or stealing the information. This study applies the Mobile Agent scheme to cope with the problem. Since a Mobile Agent is a program, which can move among hosts and

  10. Transforming patient care by introducing an electronic medical records initiative in a developing country.

    PubMed

    Shuaib, Waqas; Suarez, Julia Marielly; Romero, Juan David; Pamello, Carlos Dillon; Alweis, Richard; Khan, Aizaaz Ali; Shah, Syed Raza; Shahid, Hassan; PierreCharles, Serge B; Sanchez, Laura Rosemary

    2016-12-01

    The incorporation of an electronic medical record into patient care is a priority in developed countries, but faces significant obstacles for adoption in developing countries. The goal of our study was to define and assess the efficiency of a personalized intervention on village physicians' use of electronic medical records in rural community health services of underprivileged areas. Six towns were selected with two bordering local health stations from each town. One was randomly given to the intervention group and the other to the control group. A structured on-site intervention was provided to village physicians in the intervention group, for 7 months. The results showed that in the intervention group, the percentage of households with complete records increased. The percentage of clinic medical records and complete child vaccination in the intervention group also increased from 2 to 14 percent (p = <0.05) and from 10 to 23 percent (p = 0.05), respectively. Our investigation demonstrated that on-site education, supervision, and technical support directly correlate with improved use of electronic medical record. Our results report the challenges in implementing such a system and the steps being taken to enhance likelihood of sustainability.

  11. 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.

  12. University of Arkansas for Medical Sciences electronic health record and medical informatics training for undergraduate health professionals.

    PubMed

    Hart, Jan K; Newton, Bruce W; Boone, Steven E

    2010-07-01

    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.

  13. 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

  14. 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.

  15. 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

  16. [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.

  17. Psychiatric Emergencies

    PubMed Central

    Bayrakal, Sadi

    1972-01-01

    Dr. Bayrakal believes that the time has come for the family physician to deal with minor psychiatric disturbances in his office as well as psychiatric emergencies in the emergency department. The newly emerging medico-social philosophy of both the federal and provincial governments, he says, is giving greater responsibility and authority to the family physician in every area of medicine, including psychiatry. The author discusses major psychiatric emergencies (suicide, suicidal attempt, homicide, social scandal, as well as other psychiatric emergencies) on the ward including adolescent psychiatry. (The descriptions and treatment procedures are given on a concrete clinical level without theoretical overload.) In the family physician's work, psychological understanding is of profound importance. Giving him the added scope of psychiatric consideration to see the patient in bio-psycho-social totality will enable him to practice a more humanized form of medicine. PMID:20468779

  18. Liver Illness and Psychiatric Patients

    PubMed Central

    Carrier, Paul; Debette-Gratien, Marilyne; Girard, Murielle; Jacques, Jérémie; Nubukpo, Philippe; Loustaud-Ratti, Véronique

    2016-01-01

    Patients with psychiatric disorders are usually more exposed to multiple somatic illnesses, including liver diseases. Specific links are established between psychiatric disorders and alcohol hepatitis, hepatitis B, and hepatitis C in the population as a whole, and specifically in drug abusers. Metabolic syndrome criteria, and associated steatosis or non-alcoholic steato-hepatitis (NASH) are frequent in patients with chronic psychiatric disorders under psychotropic drugs, and should be screened. Some psychiatric medications, such as neuroleptics, mood stabilizers, and a few antidepressants, are often associated with drug-induced liver injury (DILI). In patients with advanced chronic liver diseases, the prescription of some specific psychiatric treatments should be avoided. Psychiatric disorders can be a limiting factor in the decision-making and following up for liver transplantation. PMID:28123443

  19. A Delphi study among internal medicine clinicians to determine which therapeutic information is essential to record in a medical record.

    PubMed

    van Unen, Robert J; Tichelaar, Jelle; Nanayakkara, Prabath W B; van Agtmael, Michiel A; Richir, Milan C; de Vries, Theo P G M

    2015-12-01

    Several studies have demonstrated that using a template for recording general and diagnostic information in the medical record (MR) improves the completeness of MR documentation, communication between doctors, and performance of doctors. However, little is known about how therapeutic information should be structured in the MR. The aim of this study was to investigate which specific therapeutic information registrars and consultants in internal medicine consider essential to record in the MR. Therefore, we carried out a 2-round Internet Delphi study. Fifty-nine items were assessed on a 5-point scale; an item was considered important if ≥ 80% of the respondents awarded it a score of 4 or 5. In total, 26 registrars and 30 consultants in internal medicine completed both rounds of the study. Overall, they considered it essential to include information about 11 items in the MR. Subgroup analyses revealed that the registrars considered 8 additional items essential, whereas the consultants considered 1 additional item essential to record. Study findings can be used as a starting point to develop a structured section of the MR for therapeutic information for both paper and electronic MRs. This section should contain at least 11 items considered essential by registrars and clinical consultants in internal medicine.

  20. An Evaluation of Authentic Learning in an Electronic Medical Records System

    ERIC Educational Resources Information Center

    Stuart, Sandra L.

    2013-01-01

    This study examined participants' perceptions of the effectiveness of a new job-training program designed to enhance the authentic learning in adult learners using an electronic medical records system at a naval health clinic. This job-training program lacked data about participants' perceptions of this learning process by which to gauge its…

  1. Integrating traditional nursing service orientation content with electronic medical record orientation.

    PubMed

    Harton, Brenda B; Borrelli, Larry; Knupp, Ann; Rogers, Necolen; West, Vickie R

    2009-01-01

    Traditional nursing service orientation classes at an acute care hospital were integrated with orientation to the electronic medical record to blend the two components in a user-friendly format so that the learner is introduced to the culture, processes, and documentation methods of the organization, with an opportunity to document online in a practice domain while lecture and discussion information is fresh.

  2. Strategies Nurse Managers Used to Offset Challenges during Electronic Medical Records Implementation: A Case Study

    ERIC Educational Resources Information Center

    Easterling, Latasha

    2015-01-01

    The purpose of this qualitative, descriptive case study was to discover successful approaches used, by nurse managers, to reduce barriers during the implementation of electronic medical record system in one hospital. Fourteen nurse managers were interviewed from an academic health science center in Mississippi. A pilot study was conducted to…

  3. Evolution of Medication Administration Workflow in Implementing Electronic Health Record System

    ERIC Educational Resources Information Center

    Huang, Yuan-Han

    2013-01-01

    This study focused on the clinical workflow evolutions when implementing the health information technology (HIT). The study especially emphasized on administrating medication when the electronic health record (EHR) systems were adopted at rural healthcare facilities. Mixed-mode research methods, such as survey, observation, and focus group, were…

  4. Electronic Medical Records Adoption and Usage among Osteopathic Physicians in New York State

    ERIC Educational Resources Information Center

    Rosenthal, Jon I.

    2012-01-01

    In 2010, the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology reported a slow rate of adoption of electronic medical records. The present research sought to explore possible reasons for this situation by examining factors that distinguished between users and nonusers of electronic…

  5. 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 records. 1801.31 Section 1801.31 National Defense Other Regulations Relating to National Defense NATIONAL COUNTERINTELLIGENCE CENTER PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters §...

  6. 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 records. 1801.31 Section 1801.31 National Defense Other Regulations Relating to National Defense NATIONAL COUNTERINTELLIGENCE CENTER PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters §...

  7. 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 records. 1801.31 Section 1801.31 National Defense Other Regulations Relating to National Defense NATIONAL COUNTERINTELLIGENCE CENTER PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters §...

  8. 32 CFR 1801.31 - Special procedures for medical and psychological records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 32 National Defense 6 2010-07-01 2010-07-01 false Special procedures for medical and psychological records. 1801.31 Section 1801.31 National Defense Other Regulations Relating to National Defense NATIONAL COUNTERINTELLIGENCE CENTER PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters §...

  9. 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 records. 1801.31 Section 1801.31 National Defense Other Regulations Relating to National Defense NATIONAL COUNTERINTELLIGENCE CENTER PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters §...

  10. Are Persons Reporting "Near-Death Experiences" Really Near Death? A Study of Medical Records.

    ERIC Educational Resources Information Center

    Stevenson, Ian; And Others

    1990-01-01

    Examination of medical records from 40 patients who reported unusual experiences during an illness or injury revealed that only 18 patients were judged to have had serious, life-threatening conditions, while 33 believed they had been dead or near death. Findings suggest that an important precipitator of so-called near-death experience is belief…

  11. 29 CFR 1915.1020 - Access to employee exposure and medical records.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 29 Labor 7 2010-07-01 2010-07-01 false Access to employee exposure and medical records. 1915.1020 Section 1915.1020 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR (CONTINUED) OCCUPATIONAL SAFETY AND HEALTH STANDARDS FOR SHIPYARD...

  12. Developing a Systematic Architecture Approach for Designing an Enhanced Electronic Medical Record (EEMR) System

    ERIC Educational Resources Information Center

    Aldukheil, Maher A.

    2013-01-01

    The Healthcare industry is characterized by its complexity in delivering care to the patients. Accordingly, healthcare organizations adopt and implement Information Technology (IT) solutions to manage complexity, improve quality of care, and transform to a fully integrated and digitized environment. Electronic Medical Records (EMR), which is…

  13. Health Care Professionals' Perceptions of the Use of Electronic Medical Records

    ERIC Educational Resources Information Center

    Adeyeye, Adebisi

    2015-01-01

    Electronic medical record (EMR) use has improved significantly in health care organizations. However, many barriers and factors influence the success of EMR implementation and adoption. The purpose of the descriptive qualitative single-case study was to explore health care professionals' perceptions of the use of EMRs at a hospital division of a…

  14. 32 CFR 1901.31 - 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 records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters §...

  15. 32 CFR 1901.31 - 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 records. 1901.31 Section 1901.31 National Defense Other Regulations Relating to National Defense CENTRAL INTELLIGENCE AGENCY PUBLIC RIGHTS UNDER THE PRIVACY ACT OF 1974 Additional Administrative Matters §...

  16. Organizational Leader Sensemaking in Healthcare Process Changes: The Development of the Electronic Medical Records Expectation Questionnaire

    ERIC Educational Resources Information Center

    Riesenmy, Kelly Rouse

    2011-01-01

    Physicians play a unique role in the adoption of electronic medical records (EMR) within the healthcare organization. As leaders, they are responsible for setting the standards for this new technology within their sphere of influence while concurrently being required to learn and integrate EMR into their own workflow and process as the recipients…

  17. [The development and operation of a package inserts service system for electronic medical records].

    PubMed

    Yamada, Hidetoshi; Nishimura, Sachiho; Shimamori, Yoshimitsu; Sato, Seiji; Hayase, Yukitoshi

    2003-03-01

    To promote the appropriate use of pharmaceuticals and to prevent side effects, physicians need package inserts on medicinal drugs as soon as possible. A medicinal drug information service system was established for electronic medical records to speed up and increase the efficiency of package insert communications within a medical institution. Development of this system facilitates access to package inserts by, for example, physicians. The time required to maintain files of package inserts was shortened, and the efficiency of the drug information service increased. As a source of package inserts for this system, package inserts using a standard generalized markup language (SGML) form were used, which are accessible to the public on the homepage of the Organization for Pharmaceutical Safety and Research (OPSR). This study found that a delay occurred in communicating revised package inserts from pharmaceutical companies to the OPSR. Therefore a pharmaceutical department page was set up as part of the homepage of the medical institution for electronic medical records to shorten the delay in the revision of package inserts posted on the medicinal drug information service homepage of the OPSR. The usefulness of this package insert service system for electronic medical records is clear. For more effective use of this system based on the OPSR homepage pharmaceutical companies have been requested to provide quicker updating of package inserts.

  18. Performance improvement indicators of the Medical Records Department and Information Technology (IT) in hospitals

    PubMed Central

    Ajami, Sima; Ketabi, Saedeh; Torabiyan, Fatemeh

    2015-01-01

    Medical Record Department (MRD) has a vital role in making short and long term plans to improve health system services. The aim of this study was to describe performance improvement indicators of hospital MRD and information technology (IT). Collection of Data: A search was conducted in various databases, through related keywords in articles, books, and abstracts of conferences from 2001 to 2009. About 58 articles and books were available which were evaluated and finally 15 of them were selected based on their relevance to the study. MRD must be capable of supporting tasks such as patient care and continuity, institute management processes, medical education programs, medical research, communication between different wards of a hospital and administrative and medical staff. The use of IT in MRD can facilitate access to department, expedite communication within and outside department, reduce space with electronic medical records, reduce costs, accelerate activities such as coding by use of coding guide software and facilitate retrieval of records that will ultimately improve the performance of MRD. PMID:26150874

  19. Use of the electronic medical record for trauma resuscitations: how does this impact documentation completeness?

    PubMed

    Bilyeu, Pam; Eastes, Lynn

    2013-01-01

    Although many trauma centers across the country have implemented electronic medical records (EMRs) for inpatient documentation, they have avoided the use of EMR during the fast-paced trauma resuscitations. The objective of this study was to determine whether documenting electronically during trauma resuscitations has resulted in improvement or degradation of the completeness of data recorded. Forty critical data points were evaluated in 100 pre-EMR charts and 100 post-EMR charts. There was improvement in completeness of charting in 25% of the electronic records reviewed and degradation of completeness of charting in 18% of the records, for a net improvement in completeness of charting of 7% in the electronic records reviewed.

  20. Utilizing Electronic Health Record Information to Optimize Medication Infusion Devices: A Manual Data Integration Approach.

    PubMed

    Chuk, Amanda; Maloney, Robert; Gawron, Joyce; Skinner, Colin

    Health information technology is increasingly utilized within healthcare delivery systems today. Two examples of this type of technology include the capture of patient-specific information within an electronic health record and intravenous medication infusion devices equipped with dose error reduction software known as drug libraries. Automatic integration of these systems, termed intravenous (IV) interoperability, should serve as the goal toward which all healthcare systems work to maximize patient safety. For institutions lacking IV interoperability, we describe a manual approach of querying the electronic health record to incorporate medication administration information with data from infusion device software to optimize drug library settings. This approach serves to maximize utilization of available information to optimize medication safety provided by drug library software.

  1. Utilizing Electronic Health Record Information to Optimize Medication Infusion Devices: A Manual Data Integration Approach.

    PubMed

    Chuk, Amanda; Maloney, Robert; Gawron, Joyce; Skinner, Colin

    2015-05-23

    Health information technology is increasingly utilized within healthcare delivery systems today. Two examples of this type of technology include the capture of patient-specific information within an electronic health record and intravenous medication infusion devices equipped with dose error reduction software known as drug libraries. Automatic integration of these systems, termed intravenous (IV) interoperability, should serve as the goal toward which all healthcare systems work to maximize patient safety. For institutions lacking IV interoperability, we describe a manual approach of querying the electronic health record to incorporate medication administration information with data from infusion device software to optimize drug library settings. This approach serves to maximize utilization of available information to optimize medication safety provided by drug library software.

  2. Design of electronic medical record user interfaces: a matrix-based method for improving usability.

    PubMed

    Kuqi, Kushtrim; Eveleigh, Tim; Holzer, Thomas; Sarkani, Shahryar; Levin, James E; Crowley, Rebecca S

    2013-01-01

    This study examines a new approach of using the Design Structure Matrix (DSM) modeling technique to improve the design of Electronic Medical Record (EMR) user interfaces. The usability of an EMR medication dosage calculator used for placing orders in an academic hospital setting was investigated. The proposed method captures and analyzes the interactions between user interface elements of the EMR system and groups elements based on information exchange, spatial adjacency, and similarity to improve screen density and time-on-task. Medication dose adjustment task time was recorded for the existing and new designs using a cognitive simulation model that predicts user performance. We estimate that the design improvement could reduce time-on-task by saving an average of 21 hours of hospital physicians' time over the course of a month. The study suggests that the application of DSM can improve the usability of an EMR user interface.

  3. Using the GAD-Q-IV to identify generalized anxiety disorder in psychiatric treatment seeking and primary care medical samples.

    PubMed

    Moore, Michael T; Anderson, Nicholas L; Barnes, Jill M; Haigh, Emily A P; Fresco, David M

    2014-01-01

    The fourth edition of the Generalized Anxiety Disorder Questionnaire (GAD-Q-IV) is a self-report measure that is commonly used to screen for the presence of generalized anxiety disorder (GAD). The current investigation attempted to identify an optimal cut score using samples obtained from an outpatient psychiatric (n=163) and primary care clinic (n=99). Results indicated that a cut score of 7.67 provided an optimal balance of sensitivity (.85) and specificity (.74) comparable to a previously identified cut score (5.7) across both samples (sensitivity=.90, specificity=.66). However, both cut scores were consistently outperformed by a score representing the criteria for GAD described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (sensitivity=.89, specificity=.82).

  4. Identifying risk factors for healthcare-associated infections from electronic medical record home address data

    PubMed Central

    2010-01-01

    Background Residential address is a common element in patient electronic medical records. Guidelines from the U.S. Centers for Disease Control and Prevention specify that residence in a nursing home, skilled nursing facility, or hospice within a year prior to a positive culture date is among the criteria for differentiating healthcare-acquired from community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections. Residential addresses may be useful for identifying patients residing in healthcare-associated settings, but methods for categorizing residence type based on electronic medical records have not been widely documented. The aim of this study was to develop a process to assist in differentiating healthcare-associated from community-associated MRSA infections by analyzing patient addresses to determine if residence reported at the time of positive culture was associated with a healthcare facility or other institutional location. Results We identified 1,232 of the patients (8.24% of the sample) with positive cultures as probable cases of healthcare-associated MRSA based on residential addresses contained in electronic medical records. Combining manual review with linking to institutional address databases improved geocoding rates from 11,870 records (79.37%) to 12,549 records (83.91%). Standardization of patient home address through geocoding increased the number of matches to institutional facilities from 545 (3.64%) to 1,379 (9.22%). Conclusions Linking patient home address data from electronic medical records to institutional residential databases provides useful information for epidemiologic researchers, infection control practitioners, and clinicians. This information, coupled with other clinical and laboratory data, can be used to inform differentiation of healthcare-acquired from community-acquired infections. The process presented should be extensible with little or no added data costs. PMID:20849635

  5. Medical Individualism or Medical Familism? A Critical Analysis of China's New Guidelines for Informed Consent: The Basic Norms of the Documentation of the Medical Record.

    PubMed

    Bian, Lin

    2015-08-01

    Modern Western medical individualism has had a significant impact on health care in China. This essay demonstrates the ways in which such Western-style individualism has been explicitly endorsed in China's 2010 directive: The Basic Norms of the Documentation of the Medical Record. The Norms require that the patient himself, rather than a member of his family, sign each informed consent form. This change in clinical practice indicates a shift toward medical individualism in Chinese healthcare legislation. Such individualism, however, is incompatible with the character of Chinese familism that is deeply rooted in the Chinese ethical tradition. It also contradicts family-based patterns of health care in China. Moreover, the requirement for individual informed consent is incompatible with numerous medical regulations promulgated in the past two decades. This essay argues that while Chinese medical legislation should learn from relevant Western ideas, it should not simply copy such practices by importing medical individualism into Chinese health care. Chinese healthcare policy is properly based on Chinese medical familist resources.

  6. Agreement between self-report and prescription data in medical records for pregnant women.

    PubMed

    Sarangarm, Preeyaporn; Young, Bonnie; Rayburn, William; Jaiswal, Pallavi; Dodd, Melanie; Phelan, Sharon; Bakhireva, Ludmila

    2012-03-01

    BACKGROUND Clinical teratology studies often rely on patient reports of medication use in pregnancy with or without other sources of information. Electronic medical records (EMRs), administrative databases, pharmacy dispensing records, drug registries, and patients' self-reports are all widely used sources of information to assess potential teratogenic effect of medications. The objective of this study was to assess comparability of self-reported and prescription medication data in EMRs for the most common therapeutic classes. METHODS The study population included 404 pregnant women prospectively recruited from five prenatal care clinics affiliated with the University of New Mexico. Self-reported information on prescription medications taken since the last menstrual period (LMP) was obtained by semistructured interviews in either English or Spanish. For validation purposes, EMRs were reviewed to abstract information on medications prescribed between the LMP and the date of the interview. Agreement was estimated by calculating a kappa (κ) coefficient, sensitivity, and specificity. RESULTS In this sample of socially-disadvantaged (i.e., 67.9% high school education or less, 48.5% no health insurance), predominantly Latina (80.4%) pregnant women, antibiotics and antidiabetic agents were the most prevalent therapeutic classes. The agreement between the two sources substantially varied by therapeutic class, with the highest level of agreement seen among antidiabetic and thyroid medications (κ ≥0.8) and the lowest among opioid analgesics (κ = 0.35). CONCLUSIONS Results indicate a high concordance between self-report and prescription data for therapeutic classes used chronically, while poor agreement was observed for medications used intermittently, on an 'as needed" basis, or in short courses.

  7. Contribution of Electronic Medical Records to the Management of Rare Diseases

    PubMed Central

    Bremond-Gignac, Dominique; Lewandowski, Elisabeth; Copin, Henri

    2015-01-01

    Purpose. Electronic health record systems provide great opportunity to study most diseases. Objective of this study was to determine whether electronic medical records (EMR) in ophthalmology contribute to management of rare eye diseases, isolated or in syndromes. Study was designed to identify and collect patients' data with ophthalmology-specific EMR. Methods. Ophthalmology-specific EMR software (Softalmo software Corilus) was used to acquire ophthalmological ocular consultation data from patients with five rare eye diseases. The rare eye diseases and data were selected and collected regarding expertise of eye center. Results. A total of 135,206 outpatient consultations were performed between 2011 and 2014 in our medical center specialized in rare eye diseases. The search software identified 29 congenital aniridia, 6 Axenfeld/Rieger syndrome, 11 BEPS, 3 Nanophthalmos, and 3 Rubinstein-Taybi syndrome. Discussion. EMR provides advantages for medical care. The use of ophthalmology-specific EMR is reliable and can contribute to a comprehensive ocular visual phenotype useful for clinical research. Conclusion. Routinely EMR acquired with specific software dedicated to ophthalmology provides sufficient detail for rare diseases. These software-collected data appear useful for creating patient cohorts and recording ocular examination, avoiding the time-consuming analysis of paper records and investigation, in a University Hospital linked to a National Reference Rare Center Disease. PMID:26539543

  8. Information on functioning found in the medical records of patients with stroke

    PubMed Central

    Lee, Haejung; Seo, Sunghwa; Song, Jumin

    2016-01-01

    [Purpose] To explore data on functioning in the medical records of patients with stroke by linking them to the ICF. [Subjects and Methods] The admission and discharge summaries of patients’ electronic medical records (EMRs) were investigated. Information on functioning included in the summaries were mapped into the ICF. Each of the linked categories of ICF was analyzed using frequency and percentage analysis. [Results] Thirty stroke patients’ records were evaluated. A total of 1,832 items on functioning in the EMRs were found to be linked to eighty-five categories of the ICF. The majority of those categories (52.9%) belonged to the body function domain, whereas only 8.2% were environment factors. Categories in the domain of activity and participation, and body structure were found to be 22.4% and 16.5% respectively. In each domain, the most frequently found categories were muscle power function (b730), structure of brain (s110), walking (d450), and products or substances for personal consumption (e110). [Conclusion] It was found that the admission and discharge summary in the current medical records of patients with stroke contained much noticeable information on functioning and the data on functioning may be linked to the ICF. Further study is needed to adapt ICF in Korean clinical settings. PMID:27821922

  9. Diagnosis and treatment of asthma in children: usefulness of a review of medical records.

    PubMed Central

    Neville, R G; Bryce, F P; Robertson, F M; Crombie, I K; Clark, R A

    1992-01-01

    In order to tackle the problems of underdiagnosis and undertreatment of asthma in childhood general practitioners need to be aware of which children in their practices have or might have asthma. In an effort to identify a cohort of asthmatic or potentially asthmatic children a trained audit facilitator studied all the medical records of children aged between one year and 15 years who were registered with 12 Tayside general practices. From a total of 10,685 medical records the frequency of 'key items' sometimes associated with asthma were as follows: one or more episodes of bronchospasm or wheeze 23.7% of children, persistent cough 23.2%, treatment with anti-asthma therapy in the past 20.0%, exercise induced cough or wheeze 5.2% and history of 'wheezy bronchitis' 4.6%. However, in only 896 children (8.4%) had a formal diagnosis of asthma been made. Of all the children, 5.4% had received a prescription for anti-asthma medication within the past three months. Only 1.2% were taking an inhaled corticosteroid and 1.0% sodium cromoglycate, but many more were taking inhaled bronchodilators (3.1%) and oral bronchodilators (1.7%). The findings suggest that a systematic review of medical records by a trained facilitator can identify those children who could benefit from clinical review. Practices who wish to know which of their children have or might have asthma should consider using medical record review to search for key items associated with asthma. PMID:1297369

  10. The Effects of Sociodemographic Factors on Psychiatric Diagnosis

    PubMed Central

    Choi, Mal Rye; Eun, Hun-Jeong; Yoo, Tai P.; Yun, Youngmi; Wood, Christopher; Kase, Michael; Park, Jong-Il

    2012-01-01

    Objective Several studies have reported that ethnic differences influence psychiatric diagnoses. Some previous studies reported that African Americans and Hispanics are diagnosed with schizophrenia spectrum disorders more frequently than Caucasians, and that Caucasians are more likely to be diagnosed with affective disorders than other ethnic groups. We sought to identify associations between sociodemographic factors and psychiatric diagnosis. Methods We retrospectively examined the medical records of all psychiatric inpatients (ages over 18 years) treated at Kern county mental hospital (n=2,051) between July 2003 and March 2007 for demographic, clinical information, and discharge diagnoses. Results African American and Hispanic males were more frequently diagnosed with schizophrenia spectrum disorders than Caucasians, whereas Caucasian females were more frequently diagnosed with affective disorders than females in the other ethnic groups, suggesting that patient ethnicity and gender may influence clinical diagnoses. Demographic variables, that is, a lower education, failure of marriage, homelessness, and low quality insurance, were found to be significantly associated with a diagnosis of schizophrenia spectrum disorders after adjusting for clinical variables. And, the presence of a family psychiatric history, failure of marriage, not-homelessness, and quality insurance were found to be associated with a diagnosis of affective disorders. Conclusion Our results show that these demographic factors, including ethnicity, have effects on diagnoses in psychiatric inpatients. Furthermore, these variables may help prediction of psychiatric diagnoses. PMID:22993517

  11. Adoption of a Nationwide Shared Medical Record in France: Lessons Learnt after 5 Years of Deployment

    PubMed Central

    Séroussi, Brigitte; Bouaud, Jacques

    2016-01-01

    Information sharing among health practitioners, either for coordinated or unscheduled care, is necessary to guarantee care quality and patient safety. In most countries, nationwide programs have provided tools to support information sharing, from centralized care records to health information exchange between electronic health records (EHRs). The French personal medical record (DMP) is a centralized patient-controlled record, created according to the opt-in consent model. It contains the documents health practitioners voluntarily push into the DMP from their EHRs. Five years after the launching of the program in December 2010, there were nearly 570,000 DMPs covering only 1.5% of the target population in December 2015. Reasons for this poor level of adoption are discussed in the perspective of other countries’ initiatives. The new French governmental strategy for the DMP deployment in 2016 is outlined, with the implementation of measures similar to the US Meaningful Use. PMID:28269907

  12. Nutraceuticals in psychiatric practice.

    PubMed

    Chiappedi, Matteo; de Vincenzi, Silvia; Bejor, Maurizio

    2012-08-01

    Nutraceuticals can be defined as food components or active principles present in aliments which have positive effects for health and quality of life, including preventing or treating disorders. Herbal and "natural" food supplements are increasingly used to treat different psychiatric disorders, often as "self-prescribed" therapies. With factors such as chronic illness, poor health, emotional distress, and quality of life influencing the desire for complementary medicine, patients with comorbid medical and psychiatric problems seem likely to turn to this approach. We reviewed the most commonly used herbal and dietary supplements for which a certain efficacy on psychiatric symptoms or disorders has been claimed, checking current Pubmed-indexed literature (the most important being St. John's wort, Omega-3 fatty acids, valerian, Kava, Ginkgo, folate, B vitamins, S-Adenosylmethionine, inositol, alfa-lactoalbumin and passionflower). There is evidence of efficacy for some of these herbs an supplements, proved also by Cochrane's meta-analysis. However many different areas (including efficacy, tolerability, optimal dosing, adequate shelf life, drug and non-pharmacological interactions) need to be thoroughly studied; moreover political decisions need to be scientifically guided in order to best serve psychiatric patients' interests and to prevent using of expensive and sometimes un-useful therapies. This implies that a scientific strategy is needed to rule out any third-part economical interest which could in any way influence therapeutic choices. The article presents some promising patents on nutraceuticals in psychiatric practice.

  13. 28 CFR 549.41 - Voluntary admission and psychotropic medication.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... INSTITUTIONAL MANAGEMENT MEDICAL SERVICES Administrative Safeguards for Psychiatric Treatment and Medication... admitted for psychiatric treatment and medication when, in the professional judgment of qualified...

  14. Improving the Effectiveness of Physiology Record Books as a Learning Tool for First-Year Medical Students in India

    ERIC Educational Resources Information Center

    Vyas, Rashmi; Tharion, Elizabeth; Sathishkumar, Solomon

    2009-01-01

    In compliance with the Medical Council of India, preclinical medical students maintain a record of their laboratory work in physiology. The physiology record books also contain a set of questions to be answered by the students. Faculty members and students had indicated that responding to these questions did not serve the intended purpose of being…

  15. A Probabilistic Reasoning Method for Predicting the Progression of Clinical Findings from Electronic Medical Records

    PubMed Central

    Goodwin, Travis; Harabagiu, Sanda M.

    2015-01-01

    In this paper, we present a probabilistic reasoning method capable of generating predictions of the progression of clinical findings (CFs) reported in the narrative portion of electronic medical records. This method benefits from a probabilistic knowledge representation made possible by a graphical model. The knowledge encoded in the graphical model considers not only the CFs extracted from the clinical narratives, but also their chronological ordering (CO) made possible by a temporal inference technique described in this paper. Our experiments indicate that the predictions about the progression of CFs achieve high performance given the COs induced from patient records. PMID:26306238

  16. [Clinical features in fatal Spanish influenza: Japanese Army Hospital medical records investigation].

    PubMed

    Fujikura, Yuji; Kawana, Akihiko; Kato, Yasuyuki; Mizuno, Yasutaka; Kudo, Koichiro

    2010-03-01

    Pandemic influenza preparedness requires a thorough knowledge of past pandemics. Tokyo First Army Hospital medical records from January 1918 to December 1920 found recently included 132 consecutive records of those diagnosed with influenza. We report on the clinical features in 8 fatal cases. Inpatient mortality was found to be 6.1% (8/132). Cough was noted in 6 (75%) and thoracic rales in 8 (100%) on admission, mimicking pneumonia. Bloody sputum was noted in 5 (62.5%) and diarrhea in 4 (50%), with marked hemorrhagic and digestive symptoms, resembling highly pathogenic avian influenza. Clinical features may differ from seasonal influenza, making early detection and treatment essential especially in severe cases.

  17. [The practical application of the International Classification of Functioning, Disability and Health (ICF) in medical rehabilitation of psychiatric patients].

    PubMed

    Grundmann, J; Keller, K; Bräuning-Edelmann, M

    2005-12-01

    The WHO Classification of Functioning, Disability and Health enables the description of functional health, disability and impairment on an international and interdisciplinary level in a common language. The fundamental underlying assumption of this Classification, which is orientated around a bio-psycho-social model of health and impairment, has been accepted by rehabilitation scientists in general. Unfortunately, the WHO does not make any recommendations as to how this classification could be applied in practice. In this article, various problems are outlined which could occur when the ICF is applied. Furthermore an example from a psychiatric rehabilitation institution illustrates the way the ICF could serve as an instrument for an extensive rehabilitation management programme. Here, Stucki's use will be made of Rehab-Cycle model. This describes a comprehensive sequence of steps which help analyse the patients problems from a patient-centred standpoint, to set up a schedule for treatment and to evaluate the results. Within Stucki's model the ICF is used as a system to analyse problems upon which intervention can be set. This method is illustrated with an example from a rehabilitation case. Summarizing, it is pointed out that through easier communication (as a result of the ICF) interdisciplinary productivity and efficiency will increase. On this basis it is possible to achieve a more comprehensive multimodal approach in the treatment of people suffering from psychic impairments or disability.

  18. 28 CFR 549.44 - Voluntary hospitalization in a suitable facility for psychiatric care or treatment, and voluntary...

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... facility for psychiatric care or treatment, and voluntary administration of psychiatric medication. 549.44... MEDICAL SERVICES Psychiatric Evaluation and Treatment § 549.44 Voluntary hospitalization in a suitable facility for psychiatric care or treatment, and voluntary administration of psychiatric medication....

  19. 28 CFR 549.44 - Voluntary hospitalization in a suitable facility for psychiatric care or treatment, and voluntary...

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... facility for psychiatric care or treatment, and voluntary administration of psychiatric medication. 549.44... MEDICAL SERVICES Psychiatric Evaluation and Treatment § 549.44 Voluntary hospitalization in a suitable facility for psychiatric care or treatment, and voluntary administration of psychiatric medication....

  20. 28 CFR 549.44 - Voluntary hospitalization in a suitable facility for psychiatric care or treatment, and voluntary...

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... facility for psychiatric care or treatment, and voluntary administration of psychiatric medication. 549.44... MEDICAL SERVICES Psychiatric Evaluation and Treatment § 549.44 Voluntary hospitalization in a suitable facility for psychiatric care or treatment, and voluntary administration of psychiatric medication....