如何预防电子病历中存在的医疗纠纷隐患

随着医学知识的广泛普及、患者维权意识的增强,诉诸法律的医疗纠纷越来越多,病案已经作为维护医患双方合法权益的一项重要法律依据,病历书写的完整准确已经成为避免医疗纠纷不可忽视的重要环节     

电子病历质量监控和管理

通过电子病案产生全过程，强调对环节病历质量监控的重要性和做法，并对终末病历归档、编目和保存进行了讨论，以求进一步提高病案管理质量。尽可能防止差错发生。     

病历、电子病历与中医电子病历

本文从中医病历的历史演化，西医病历的发展过程出发，对中西医病历的特点进行了分析，并对电子病历及中医电子病历作了一些简单的介绍。     

电子病历面临的问题和思考

传统病历电子化的过程面临以下八个问题：①我国无电子病历的统一标准，使得信息难以整合与交换；②电子病历未得到法律上的认可，使其很难有序发展；③保静陛存在较大漏洞；④存储空间小，难以满足病历反复使用的特点；⑤电子病历质量存在许多问题；⑥医护之间的脱节现象；⑦电子病历管理制度不完善增大了病案管理难度；⑧系统软硬件的配置问题。就以上问题，本文提出了如下解决办法：①制定我国电子病历管理办法；②建立电子病历的标准；③尽快立法，得到法律保障；④采取措施提高电子病历的安全性；⑤建立、健全质量监督控制机制；⑥培养提高医护人员素质。     

儿科护理病历书写与医疗纠纷关系的探讨

根据儿科的护理病历书写现状结合<医疗事故处理条例>进行分析,护理人员病历书写欠规范,缺乏证据保全知识.提示通过规范护理病历书写,完普护理病历管理,加强护理病历质控,可望在医疗纠纷中变被动为主动,防范护理纠纷.     

电子病历应用中需注意和解决的几个问题

当前 ,医院信息系统 (HIS)正向着以病人信息为中心 ,高度集成化和多媒体化的方向发展。电子病历作为其中的一个重要组成部分 ,正在受到越来越多的关注 ,国内已有数家公司开发出了包括电子病历在内的 HIS。在此基础上 ,部分医院已经或正在开始抛弃传统的手工书写病历而代之以全新的电子病历。纵观部分医院的应用实践 ,可以肯定地说 ,电子病历的应用对临床医疗工作带来了积极的变化 ,对医院的许多方面都产生了显著的影响 ,为医院今后的发展开拓了新的空间。同时 ,我们也应承认 ,电子病历在我国尚属起步阶段 ,还有许多实际问题需要引起重视…     

加强患者病历管理在防范医疗纠纷中的作用

目的：探讨加强患者病历管理在防范医疗纠纷中起到的作用。方法随机抽取我院在病历管理改革前后的患者病历各400例,设置为观察组和观察组,对比两组病历合格率和医疗纠纷数。结果观察组患者病历的合格数比例明显高于对照组;观察组医疗纠纷例数比例少于对照组(<0.05)。结论加强患者病历管理可有效减少医疗纠纷,降低医疗风险,促进医疗体系健康发展。     

病历书写与医疗纠纷

通过对病历书写与医疗纠纷的分析,提出医护人员应健全法律意识,提高自我保护意识,认真履行告知义务,注意病历书写中的及时性、真实性、完整性、规范化,从而减少医疗纠纷。     

电子病历系统应用的实际意义

电子病历作为医院数字化的核心,已成为医院、医疗主管部门关注的热点问题.通过实施电子病历,提升了医院管理质量,提高了医院竞争力.无论是对病人的医疗保健还是医院、行业乃至社会都有十分重要的意义,同时在实施中也存在着一些问题.     

我院电子病历存在的问题与改进

电子病历是把病人在医院一系列医疗过程信息进行采集、加工、存储及处理,并客观记录的一套软件系统.其具有提取及共享信息方便、容量大、信息完整、易保存、方便快捷等实用性,是临床、教学、科研的重要资料来源.同时,因电子病历多使用模版,可复制粘贴,且在病人出院前可以修改,在使用过程中往往易出现一些问题.我院自2007年11月起使用了天健系统电子病历,在应用过程中暴露出一些病历质量缺问题,如不重视并予改进,必然是医院医疗质量缺陷产生的重要环节,也给医疗纠纷的产生留下隐患.     

基于Web的电子病案系统设计

计算机网络技术和数据库技术的发展，使得医院的信息化程度不断得到提高，也使得电子病案的发展越来越得到重视。本文阐述了电子病案在国内外的发展趋势以及如何运用B／S和C／S相结合的模式设计基于Web的电子病案系统，并结合实际对设计电子病案系统过程中必须注意的几个问题进行了探讨。     

医院信息系统中门诊电子病历的设计与研究

基于医院信息系统的设计与开发,对门诊电子病历进行了设计、研究与实现,并在此基础上分析了临床诊疗、医院管理工作对电子病历的要求,研究了电子医嘱模板的形式对临床诊疗的满足情况,与目前比较普遍采用的电子病历的设计方法作了对比。系统采用MSSQL2000数据库存储与电子病历相关的信息。利用PowerBuilder9.0编写代码与制作界面,实现整个系统的功能。     

基于电子病历识别谵妄的研究现状与展望

谵妄是老年住院患者中常见的并发症,会导致患者认知功能下降,增加老年人失能、跌倒、死亡等风险,造成沉重的社会负担。虽然目前已有多种床旁谵妄筛查量表,但谵妄临床漏诊率依旧居高不下,这可能与谵妄具有急性波动性、常于夜间发病的特点有关。随着电子病历智能化和自动化的日渐发展,已有研究探索了通过电子病历识别谵妄患者,这为谵妄的诊断和预防提供了重要帮助。本文就电子病历识别谵妄的研究现状进行回顾与总结,并对该方法的发展前景进行展望,以期为智能化诊断谵妄提供依据和奠定基础。     

机器学习在电子病历中应用的可视化分析

为探讨机器学习方法在电子病历领域应用的研究现状、研究热点与前沿,以2000～2022年中国知网数据库和Web of Science核心合集数据库中关于机器学习在电子病历中应用的相关文献为数据来源,运用CiteSpace软件绘制国家/地区、作者、机构、关键词共现以及关键词突现5个方面科学知识图谱进行可视化对比分析,以便了解国内外研究的差异,为该领域的研究和发展提供参考。     

The effects of an electronic medical record on the completeness of documentation in the anesthesia record

ObjectivesThe purpose of this study is to evaluate the completeness of anesthesia recording before and after the introduction of an electronic anesthesia record.MethodsThe study was conducted in a Korean teaching hospital where the EMR was implemented in October 2008. One hundred paper anesthesia records from July to September 2008 and 150 electronic anesthesia records during the same period in 2009 were randomly sampled. Thirty-four essential items were selected out of all the anesthesia items and grouped into automatically transferred items and manual entry items. 1, .5 and 0 points were given for each item of complete entry, incomplete entry and no entry respectively. The completeness of documentation was defined as the sum of the scores. The influencing factors on the completeness of documentation were evaluated in total and by the groups.ResultsThe average completeness score of the electronic anesthesia records was 3.15% higher than that of the paper records. A multiple regression model showed the type of the anesthesia record was a significant factor on the completeness of anesthesia records in all items (β = .98, p < .05) and automatically transferred items (β = .56, p < .01). The type of the anesthesia records had no influence on the completeness in manual entry items.ConclusionsThe completeness of an anesthesia record was improved after the implementation of the electronic anesthesia record. The reuse of the data from the EMR was the main contributor to the improved completeness.     

The diagnosis related groups enhanced electronic medical record

Problem. The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians’ coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources. Methods. Within the Electronic Medical Record (EMR) a user interface (‘DRG Control Center’) for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well. Results. With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.     

Parent satisfaction with the electronic medical record in an academic pediatric rheumatology practice

Background

Patient satisfaction has not been widely studied with respect to implementation of the electronic medical record (EMR). There are few reports of the impact of the EMR in pediatrics.

Objective

The objective of this study was to assess the impact of implementation of an electronic medical record system on families in an academic pediatric rheumatology practice.

Methods

Families were surveyed 1 month pre-EMR implementation and 3 months post-EMR implementation.

Results

Overall, EMR was well received by families. Compared with the paper chart, parents agreed the EMR improved the quality of doctor care (55% or 59/107 vs 26% or 26/99, P < .001). More parents indicated they would prefer their pediatric physicians to use an EMR (68% or 73/107 vs 51% or 50/99, P = .01).

Conclusions

Transitioning an academic pediatric rheumatology practice to an EMR can increase family satisfaction with the office visit.     

An assessment of data quality in a multi-site electronic medical record system in Haiti

ObjectivesStrong data quality (DQ) is a precursor to strong data use. In resource limited settings, routine DQ assessment (DQA) within electronic medical record (EMR) systems can be resource-intensive using manual methods such as audit and chart review; automated queries offer an efficient alternative. This DQA focused on Haiti’s national EMR – iSanté – and included longitudinal data for over 100,000 persons living with HIV (PLHIV) enrolled in HIV care and treatment services at 95 health care facilities (HCF).MethodsThis mixed-methods evaluation used a qualitative Delphi process to identify DQ priorities among local stakeholders, followed by a quantitative DQA on these priority areas. The quantitative DQA examined 13 indicators of completeness, accuracy, and timeliness of retrospective data collected from 2005 to 2013. We described levels of DQ for each indicator over time, and examined the consistency of within-HCF performance and associations between DQ and HCF and EMR system characteristics.ResultsOver all iSanté data, age was incomplete in <1% of cases, while height, pregnancy status, TB status, and ART eligibility were more incomplete (approximately 20–40%). Suspicious data flags were present for <3% of cases of male sex, ART dispenses, CD4 values, and visit dates, but for 26% of cases of age. Discontinuation forms were available for about half of all patients without visits for 180 or more days, and >60% of encounter forms were entered late. For most indicators, DQ tended to improve over time. DQ was highly variable across HCF, and within HCFs DQ was variable across indicators. In adjusted analyses, HCF and system factors with generally favorable and statistically significant associations with DQ were University hospital category, private sector governance, presence of local iSante server, greater HCF experience with the EMR, greater maturity of the EMR itself, and having more system users but fewer new users. In qualitative feedback, local stakeholders emphasized lack of stable power supply as a key challenge to data quality and use of the iSanté EMR.ConclusionsVariable performance on key DQ indicators across HCF suggests that excellent DQ is achievable in Haiti, but further effort is needed to systematize and routinize DQ approaches within HCFs. A dynamic, interactive “DQ dashboard” within iSanté could bring transparency and motivate improvement. While the results of the study are specific to Haiti’s iSanté data system, the study’s methods and thematic lessons learned holdgeneralized relevance for other large-scale EMR systems in resource-limited countries.     

Enhanced identification of eligibility for depression research using an electronic medical record search engine

Purpose

Electronic medical records (EMRs) have become part of daily practice for many physicians. Attempts have been made to apply electronic search engine technology to speed EMR review. This was a prospective, observational study to compare the speed and clinical accuracy of a medical record search engine vs. manual review of the EMR.

Methods

Three raters reviewed 49 cases in the EMR to screen for eligibility in a depression study using the electronic medical record search engine (EMERSE). One week later raters received a scrambled set of the same patients including 9 distractor cases, and used manual EMR review to determine eligibility. For both methods, accuracy was assessed for the original 49 cases by comparison with a gold standard rater.

Results

Use of EMERSE resulted in considerable time savings; chart reviews using EMERSE were significantly faster than traditional manual review (p = 0.03). The percent agreement of raters with the gold standard (e.g. concurrent validity) using either EMERSE or manual review was not significantly different.

Conclusions

Using a search engine optimized for finding clinical information in the free-text sections of the EMR can provide significant time savings while preserving clinical accuracy. The major power of this search engine is not from a more advanced and sophisticated search algorithm, but rather from a user interface designed explicitly to help users search the entire medical record in a way that protects health information.     

An electronic medical record system for ambulatory care of HIV-infected patients in Kenya

Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research. Faculty at Moi University in Kenya and Indiana and University in the USA opened adult and pediatric HIV clinics in a national referral hospital, a district hospital, and six rural health centers in western Kenya using a newly developed EMR to support comprehensive outpatient HIV/AIDS care. Demographic, clinical, and HIV risk data, diagnostic test results, and treatment information are recorded on paper encounter forms and hand-entered into a central database that prints summary flowsheets and reminders for appropriate testing and treatment. There are separate modules for monitoring the Antenatal Clinic and Pharmacy. The EMR was designed with input from clinicians who understand the local community and constraints of providing care in resource poor settings. To date, the EMR contains more than 30,000 visit records for more than 4000 patients, almost half taking antiretroviral drugs. We describe the development and structure of this EMR and plans for future development that include wireless connections, tablet computers, and migration to a Web-based platform.