New Perspectives in Medical Records


Book Description

This book provides innovative practical suggestions regarding the production and management of medical records that are designed to address the inconsistencies and errors that have been highlighted especially in relation to national eHealth programs. Challenges and lessons that have emerged from the use of clinical information and the design of medical records are discussed, and principles underpinning the implementation of health IT are critically examined. New trends in the use of clinical data are explored in depth, with analysis of issues relating to integration and sharing of patient information, data visualization, big data analytics, and the requirements of modern electronic health records. The spirit pervading the book is one of co-production, in which the needs of practitioners are taken into account from the outset. Readers will learn the basic concepts of how clinical information emanating from the doctor–patient relationship can be effectively integrated with genetic and environmental data and analyzed by complex algorithms with the goal of improving medical decision making and patient care. The book, written by European experts and researchers, will be of interest to all stakeholders in the field, including doctors, technicians, and policy makers.




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.




Registries for Evaluating Patient Outcomes


Book Description

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.




Medical Record Auditor


Book Description

"This book helps readers understand the principles of medical record documentation and chart auditing. It introduces readers to principles of medical record documentation and how to conduct a medical record chart review in the physcian's or outpatient office"--Provided by publisher.




Electronic Health Records


Book Description

Resource added for the Health Information Technology program 105301.







Medical Records and the Law


Book Description

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




Medical Records and the Law


Book Description

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.