A study on construction of 7-class electronic medical records system

2012 ◽  
Author(s):  
Hu Shengli ◽  
Chi Jinqing
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Medical Records System

scholarly journals 530 An Audit of Appropriate Documentation Following Urethral Catheterisation

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
I Dokubo ◽  
J Armitage
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Clinical Care ◽  
Medical Personnel ◽  
Urethral Catheter ◽  
Residual Volume ◽  
Urethral Catheterisation ◽  
Catheter Size ◽  
Medical Records System ◽  
Insertion Process

Abstract Introduction Urethral catheterisation is a procedure frequently done in the hospital by medical personnel. Appropriate documentation is necessary to ensure safe clinical care and to reduce the risk of litigation. Method We randomly reviewed electronic notes of patients seen by the on-call urology team who had a urethral catheter inserted in September 2020. Reviewing the trust’s guidelines, we considered that appropriate documentation should include reference to the following 10 items; indication, chaperone present, consent obtained, groin examination, catheter size, catheter type, insertion process, urine colour, water in balloon and residual volume were reviewed. Results A total of 50 patients were included. 72%(36/50) were inserted by a member of the urology team. Only 28%(14/50) had all 10 items documented. Indication for catheterisation was best documented at 94%(47/50) while presence of a chaperone and groin examination (i.e. presence of a foreskin and its replacement post-catheterisation) were the lowest at 44%(22/50). Conclusions This study shows there is low compliance to adequate documentation of urethral catheterisation. A ‘smart phrase’ has been developed for use with our Trusts electronic medical records system to assist clinicians with appropriate documentation. Clinicians that use the phrase ‘.icat’ are prompted to document all 10 requisite items. This uses the mnemonic i-CATHETAR [indication, Chaperone and consent, groin Assessment, Tube (catheter size and type), insertion process (Hard/Easy), urine Tint, Aqua in balloon, Residual volume]. A second audit cycle is currently being done to review the effectiveness of this intervention.

scholarly journals Factors affecting the utilisation of electronic medical records system in Malawian central hospitals

2017 ◽  
Vol 29 (3) ◽  
pp. 247 ◽  
Author(s):  
Khwima E. Mkalira Msiska ◽  
Andrew Kumitawa ◽  
Benjamin Kumwenda
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Factors Affecting ◽  
Medical Records System

RAPID: An electronic medical records system for radiation oncology

1997 ◽  
Vol 7 (1) ◽  
pp. 4-10 ◽  
Author(s):  
Scott L. Sailer ◽  
Joel E. Tepper ◽  
Larry Margolese-Malin ◽  
Julian G. Rosenman ◽  
Edward L. Chaney
Keyword(s):  
Electronic Medical Records ◽  
Radiation Oncology ◽  
Medical Records ◽  
Medical Records System

Improving adherence to safe prescription guidelines for Dapsone: harnessing an enhanced electronic medical records system and a team approach

2012 ◽  
Vol 51 (3) ◽  
pp. 349-354 ◽  
Author(s):  
Ching Yin Neoh ◽  
Elizabeth A.L. Tian ◽  
Cindy Choi ◽  
Hui Hui Leong ◽  
Audrey W.H. Tan ◽  
...  
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Team Approach ◽  
Medical Records System

scholarly journals The Risk of Osteonecrosis of the Jaws in Taiwanese Osteoporotic Patients Treated With Oral Alendronate or Raloxifene

2014 ◽  
Vol 99 (8) ◽  
pp. 2729-2735 ◽  
Author(s):  
Wei-Yih Chiu ◽  
Jung-Yien Chien ◽  
Wei-Shiung Yang ◽  
Jyh-Ming Jimmy Juang ◽  
Jang-Jaer Lee ◽  
...  
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Drug Exposure ◽  
Independent Predictor ◽  
Contributing Factors ◽  
Taiwanese Population ◽  
Duration Of Treatment ◽  
Osteonecrosis Of The Jaws ◽  
Prevention Of Osteoporosis ◽  
Medical Records System

Background: This study aimed to explore the possible association between osteonecrosis of the jaws (ONJ) and oral alendronate or raloxifene used for osteoporosis and to estimate its absolute and attributable risks in the Taiwanese population. Methods: Using an electronic medical records system and manual confirmation of ONJ, we identified patients who began taking alendronate or raloxifene for osteoporosis and developed ONJ between January 2000 and April 2012. Results: The incidence of ONJ associated with oral alendronate for the management of osteoporosis began after 1 year of drug exposure and progressively increased with longer durations of therapy, specifically from 0.23% to 0.92% as the duration of treatment went from 2 years to 10 years. The overall frequency of ONJ related to oral alendronate over a 12-year period was 0.55%. The incidence rate of ONJ attributed to alendronate exposure was 283 per 100 000 persons per year. On multivariate Cox proportional analysis, adjusting for the potential confounders, alendronate remains an independent predictor for ONJ occurrence [hazard ratio 7.42 (1.02–54.09)] compared with raloxifene. Advanced age, drug duration, and coexisting diabetes and rheumatoid arthritis are contributing factors to the development of oral alendronate-related ONJ. Conclusion: We provided the evidence to support the association of ONJ with oral alendronate used in the treatment or prevention of osteoporosis.

Sign in / Sign up

Export Citation Format

Share Document