Download or read book The Computer Based Patient Record written by Committee on Improving the Patient Record and published by National Academies Press. This book was released on 1997-10-28 with total page 257 pages. Available in PDF, EPUB and Kindle. Book excerpt: Most industries have plunged into data automation, but health care organizations have lagged in moving patients' medical records from paper to computers. In its first edition, this book presented a blueprint for introducing the computer-based patient record (CPR). The revised edition adds new information to the original book. One section describes recent developments, including the creation of a computer-based patient record institute. An international chapter highlights what is new in this still-emerging technology. An expert committee explores the potential of machine-readable CPRs to improve diagnostic and care decisions, provide a database for policymaking, and much more, addressing these key questions: Who uses patient records? What technology is available and what further research is necessary to meet users' needs? What should government, medical organizations, and others do to make the transition to CPRs? The volume also explores such issues as privacy and confidentiality, costs, the need for training, legal barriers to CPRs, and other key topics.
Download or read book Clinical Text Mining written by Hercules Dalianis and published by Springer. This book was released on 2018-05-14 with total page 192 pages. Available in PDF, EPUB and Kindle. Book excerpt: This open access book describes the results of natural language processing and machine learning methods applied to clinical text from electronic patient records. It is divided into twelve chapters. Chapters 1-4 discuss the history and background of the original paper-based patient records, their purpose, and how they are written and structured. These initial chapters do not require any technical or medical background knowledge. The remaining eight chapters are more technical in nature and describe various medical classifications and terminologies such as ICD diagnosis codes, SNOMED CT, MeSH, UMLS, and ATC. Chapters 5-10 cover basic tools for natural language processing and information retrieval, and how to apply them to clinical text. The difference between rule-based and machine learning-based methods, as well as between supervised and unsupervised machine learning methods, are also explained. Next, ethical concerns regarding the use of sensitive patient records for research purposes are discussed, including methods for de-identifying electronic patient records and safely storing patient records. The book’s closing chapters present a number of applications in clinical text mining and summarise the lessons learned from the previous chapters. The book provides a comprehensive overview of technical issues arising in clinical text mining, and offers a valuable guide for advanced students in health informatics, computational linguistics, and information retrieval, and for researchers entering these fields.
Download or read book Registries for Evaluating Patient Outcomes written by Agency for Healthcare Research and Quality/AHRQ and published by Government Printing Office. This book was released on 2014-04-01 with total page 385 pages. Available in PDF, EPUB and Kindle. Book excerpt: This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Download or read book Capturing Social and Behavioral Domains and Measures in Electronic Health Records written by Institute of Medicine and published by National Academies Press. This book was released on 2015-01-08 with total page 287 pages. Available in PDF, EPUB and Kindle. Book excerpt: Determinants of health - like physical activity levels and living conditions - have traditionally been the concern of public health and have not been linked closely to clinical practice. However, if standardized social and behavioral data can be incorporated into patient electronic health records (EHRs), those data can provide crucial information about factors that influence health and the effectiveness of treatment. Such information is useful for diagnosis, treatment choices, policy, health care system design, and innovations to improve health outcomes and reduce health care costs. Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 identifies domains and measures that capture the social determinants of health to inform the development of recommendations for the meaningful use of EHRs. This report is the second part of a two-part study. The Phase 1 report identified 17 domains for inclusion in EHRs. This report pinpoints 12 measures related to 11 of the initial domains and considers the implications of incorporating them into all EHRs. This book includes three chapters from the Phase 1 report in addition to the new Phase 2 material. Standardized use of EHRs that include social and behavioral domains could provide better patient care, improve population health, and enable more informative research. The recommendations of Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2 will provide valuable information on which to base problem identification, clinical diagnoses, patient treatment, outcomes assessment, and population health measurement.
Download or read book Key Capabilities of an Electronic Health Record System written by Institute of Medicine and published by National Academies Press. This book was released on 2003-07-31 with total page 36 pages. Available in PDF, EPUB and Kindle. Book excerpt: Commissioned by the Department of Health and Human Services, Key Capabilities of an Electronic Health Record System provides guidance on the most significant care delivery-related capabilities of electronic health record (EHR) systems. There is a great deal of interest in both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part, this interest is due to a growing recognition that a stronger information technology infrastructure is integral to addressing national concerns such as the need to improve the safety and the quality of health care, rising health care costs, and matters of homeland security related to the health sector. Key Capabilities of an Electronic Health Record System provides a set of basic functionalities that an EHR system must employ to promote patient safety, including detailed patient data (e.g., diagnoses, allergies, laboratory results), as well as decision-support capabilities (e.g., the ability to alert providers to potential drug-drug interactions). The book examines care delivery functions, such as database management and the use of health care data standards to better advance the safety, quality, and efficiency of health care in the United States.
Download or read book Secondary Analysis of Electronic Health Records written by MIT Critical Data and published by Springer. This book was released on 2016-09-09 with total page 435 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book trains the next generation of scientists representing different disciplines to leverage the data generated during routine patient care. It formulates a more complete lexicon of evidence-based recommendations and support shared, ethical decision making by doctors with their patients. Diagnostic and therapeutic technologies continue to evolve rapidly, and both individual practitioners and clinical teams face increasingly complex ethical decisions. Unfortunately, the current state of medical knowledge does not provide the guidance to make the majority of clinical decisions on the basis of evidence. The present research infrastructure is inefficient and frequently produces unreliable results that cannot be replicated. Even randomized controlled trials (RCTs), the traditional gold standards of the research reliability hierarchy, are not without limitations. They can be costly, labor intensive, and slow, and can return results that are seldom generalizable to every patient population. Furthermore, many pertinent but unresolved clinical and medical systems issues do not seem to have attracted the interest of the research enterprise, which has come to focus instead on cellular and molecular investigations and single-agent (e.g., a drug or device) effects. For clinicians, the end result is a bit of a “data desert” when it comes to making decisions. The new research infrastructure proposed in this book will help the medical profession to make ethically sound and well informed decisions for their patients.
Download or read book Integrated Electronic Health Records written by M. Beth Shanholtzer and published by McGraw-Hill Education. This book was released on 2020-06-11 with total page 304 pages. Available in PDF, EPUB and Kindle. Book excerpt: Developed as a comprehensive learning resource, this hands-on course for Integrated Electronic Health Records is offered through McGraw Hill's Connect. Connect uses the latest technology and learning techniques to better connect professors to their students, and students to the information and customized resources they need to master a subject. Both the worktext and the online course include coverage of EHRclinic, an education-based EHR solution for online electronic health records, practice management applications, and interoperable physician-based functionality. EHRclinic will be used to demonstrate the key applications of electronic health records. Attention is paid to providing the "why"behind each task, so that the reader can accumulate transferable skills. The coverage is focused on using an EHR program in a doctor's office, while providing additional information on how tasks might also be completed in a hospital setting.
Download or read book Electronic Health Record written by Pradeep K. Sinha and published by John Wiley & Sons. This book was released on 2012-11-27 with total page 244 pages. Available in PDF, EPUB and Kindle. Book excerpt: Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics," which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications. Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved. This book on Electronic Health Record: Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others Provides assessment of existing standards Includes a glossary of frequently used terms in the area of EHR Contains numerous diagrams and illustrations to facilitate comprehension Discusses security and reliability of data
Download or read book Patient Records and Addiction Treatment Fourth Edition written by Gerry Coughlin and published by . This book was released on 2008-09 with total page 128 pages. Available in PDF, EPUB and Kindle. Book excerpt: Since the first edition of this book in 1996, the addiction treatment field continues to undergo changes that affect the usefulness of this book. In an effort to include information that assists students and practitioners to use best practices, we have added a substantial amount of information and included additional resources for further investigation. Our format integrates current information and research, principles of sound clinical practice and practical experience. Our intention is to outline the procedures and rationale of case management and clinical documentation to give readers some background as well as information regarding current practice.
Download or read book Medical Records and the Law written by William H. Roach and published by Jones & Bartlett Learning. This book was released on 2006 with total page 613 pages. Available in PDF, EPUB and Kindle. Book excerpt: Published in conjunction with the American Health Information Management Association (AHIMA), the Fourth Edition of Medical Records and the Law is once again the ideal text for programs in HIM as well as a valuable reference resource for health professionals and those in the legal profession. Providing a useful resource to those in the legal profession, it addresses the substantial changes brought about by HIPAA and the growth of electronic health record systems and electronic data networks, retaining and updating the discussion of state laws affecting the use and disclosure of health informat
Download or read book Improving the Quality of Health Care for Mental and Substance Use Conditions written by Institute of Medicine and published by National Academies Press. This book was released on 2006-03-29 with total page 528 pages. Available in PDF, EPUB and Kindle. Book excerpt: Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are seriousâ€"for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substanceâ€"use conditions will benefit from this guide to achieving better care.
Download or read book Authoring Patient Records An Interactive Guide written by Michael P. Pagano and published by Jones & Bartlett Publishers. This book was released on 2010-02-11 with total page 210 pages. Available in PDF, EPUB and Kindle. Book excerpt: Authoring Patient Records: An Interactive Guide presents both the theory and rationale for the process of developing medical records, as well as opportunities for readers to practice the new skill. Each chapter discusses how to use the authoring process to create effective records, using examples and sample documents to help illustrate potential problems and solutions. This text has an interactive format including margin notes to help the reader assess his/her understanding, as well as opportunities to practice the authoring process being discussed. An instructor’s manual for online use is also included. Authoring Patient Records: An Interactive Guide is relevant to the training and work of: MDs, PAs, NPs, RNs, PTs, and RTs. The text will be a helpful resource in teaching health care students and as a reference for health care practitioners.
Download or read book Computer based Patient Records written by United States. General Accounting Office and published by . This book was released on 2001 with total page 52 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Medical Records and the Law written by William H. Roach Jr. and published by Jones & Bartlett Publishers. This book was released on 2006-04-18 with total page 613 pages. Available in PDF, EPUB and Kindle. Book excerpt: Published in conjunction with the American Health Information Management Association (AHIMA), Medical Records and the Law is the ideal text for programs in HIM as well as a valuable reference for health and legal professionals. The Fourth Edition features an expanded discussion of state laws affecting the use and disclosure of health information and the substantial changes brought about by HIPAA and the growth of electronic health record systems. It also discusses the highly complex interplay of federal and state laws as well as the challenging area of how patient information may be used in connection with medical research involving human subjects.
Download or read book Nursing Informatics for the Advanced Practice Nurse written by Susan McBride and published by . This book was released on 2019 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book The Patient s Medical Journal written by Sandra de Bruin and published by Skyhorse. This book was released on 2015-09-15 with total page 144 pages. Available in PDF, EPUB and Kindle. Book excerpt: An easy way to keep track of your medical records for years to come. The Patient’s Medical Journal is a medical diary for patients and their families. It is designed to help patients remember and organize medical information about their and their family’s past and present health. The information, once recorded, will come in handy when filling out medical forms for doctors and hospitals. The book is divided into sections to record all pertinent information, such as: A personal medical directory for information about health providers and insurance companies Past surgeries Major illnesses Allergies Vaccinations Current medications Lab tests And family medical history Once you’ve recorded your past, there’s a new section where you can record information for your upcoming medical visits, the purposes for the visits, and the treatment plan you’ve outlined with your health-care professional. In no time at all, you can compile a compact diary of your medical history for convenient use in the future.
Download or read book Authoring Patient Records written by Michael Pagano and published by Jones & Bartlett Learning. This book was released on 2010-10-25 with total page 210 pages. Available in PDF, EPUB and Kindle. Book excerpt: "This text offers tips and exercises for enhancing recordkeeping with minimal time extensions and illustrates the importance of effective documentation for quality care, safety, continuity of care, and legal compliance, including adherance to HIPAA regulations."--Back cover.
