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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
Telemedical record documentation: a preliminary survey
Abstract:
Telemedical records are the weak link in telemedicine. With a number of medicolegal and reimbursement issues still unresolved, telemedical record documentation will be a critical piece of the puzzle when the patient's original legal medical record must be produced. A questionnaire was distributed to active telemedicine programmes in the USA to determine how interactive teleconsultations were being documented. Forty programmes completed the questionnaire. The responses indicated a lack of consistency and a need for documentation guidelines for telemedical records.
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Related Concept Videos
Data Reporting and Recording
Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Methods of Documentation II: POMR
Methods of Documentation VII: EMR