Authoring Patient Records


Book Description

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.




Secondary Analysis of Electronic Health Records


Book Description

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.




The Computer-Based Patient Record


Book Description

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.




Integrated Electronic Health Records


Book Description

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.




Writing Patient/Client Notes


Book Description

Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.




Key Capabilities of an Electronic Health Record System


Book Description

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.




Better EHR


Book Description

Electronic Health Records (EHR) offer great potential to increase healthcare efficiency, improve patient safety, and reduce health costs. The adoption of EHRs among office-based physicians in the US has increased from 20% ten years ago to over 80% in 2014. Among acute care hospitals in US, the adoption rate today is approaching 100%. Finding relevant patient information in electronic health records' (EHRs) large datasets is difficult, especially when organized only by data type and time. Automated clinical summarization creates condition-specific displays, promising improved clinician efficiency. However, automated summarization requires new kinds of clinical knowledge (e.g., problem-medication relationships).




Medical Record


Book Description




Authoring Patient Records: An Interactive Guide


Book Description

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.